III-18. Life Skills (PAST 30 DAYS) Child has age appropriate Child has minor indications of Child has notable problems Child has profound independent living skills. No problems in independent with completing tasks problems of independent indication of problems or this living skills compared to necessary for independent living skills compared to information is unknown to same age children living compared to same age same age children. If not me. (cleanliness, diet, children (self management, addressed, child will be organization). cleaning). unable to live independently in the future. If the needs / functioning fall within a shaded box, explain why: child’s D. ADDITIONAL DETAILS OF OF NEED (OPTIONAL) CHILD’S LEVEL Attach school, medical, psychological or other evaluations that document the current special care needs and / or attach signed child’s of ‘Confirmation Needs’ forms. SECTION III. AUTHORIZATION
III-18. Life Skills (PAST 30 DAYS) Child has age appropriate independent living skills. No indication of problems or this information is unknown to me. Child has minor indications of problems in independent living skills compared to same age children (cleanliness, diet, organization). Child has notable problems with completing tasks necessary for independent living compared to same age children (self management, cleaning). Child has profound problems of independent living skills compared to same age children. If not addressed, child will be unable to live independently in the future. If the child’s needs / functioning fall within a shaded box, explain why: D. ADDITIONAL DETAILS OF CHILD’S LEVEL OF NEED (OPTIONAL) Attach school, medical, psychological or other evaluations that document the child’s current special care needs and / or attach signed ‘Confirmation of Needs’ forms. SECTION III. AUTHORIZATION
2868.docx