PLEASE COMPLETE WITH THE CLIENT Client Comments How I would like to benefit from this stay: This is important to me: I am good at: These are people who are important to me: Where I would like to live when I leave here: I would like the following people involved in this next move: Other things I would like you to know about me: I have a wellness plan which outlines how I would like to be supported when I am not well Yes No Attached PLEASE HAVE THE FAMILY OR SUPPORT PERSON COMPLETE
PLEASE COMPLETE WITH THE CLIENT Client Comments How I would like to benefit from this stay: This is important to me: I am good at: These are people who are important to me: Where I would like to live when I leave here: I would like the following people involved in this next move: Other things I would like you to know about me: I have a wellness plan which outlines how I would like to be supported when I am not well Yes No Attached PLEASE HAVE THE FAMILY OR SUPPORT PERSON COMPLETE
VCH_PHC_Referral%20Form_FINAL_Dec2011.docx