Other Personal Safety Yes Yes No No Needs: NA NA Self-Management of Symptoms or Behaviors Does the Does the person need or person need Behaviors and symptoms affecting want to set an outcome Overall strengths, functional skills, Assessment Area or want the ability to self-manage related to acquiring, person’s and abilities in this area: supports in needs in this area: retaining, or improving this area: skills in this area? Yes Yes Ability to self-manage No No that symptoms or behavior NA NA may otherwise result in an incident Yes Yes Ability to self-manage No No symptoms or behavior that NA NA may otherwise result in suspension or termination of services Yes Yes Other symptoms or behaviors No No that may jeopardize the health NA NA and safety of the person or others Yes Yes No No Other Symptoms or NA NA Behaviors: Yes Yes No No Other Symptoms or NA NA Behaviors: Assessment and initial service planning meeting participants: Name Signature Title Date Person Completing Assessment
Other Personal Safety Needs: Yes No NA Yes No NA Self-Management of Symptoms or Behaviors Assessment Area Does the person need or want supports in this area: Overall strengths, functional skills, and abilities in this area: Behaviors and symptoms affecting the person’s ability to self-manage needs in this area: Does the person need or want to set an outcome related to acquiring, retaining, or improving skills in this area? Ability to self-manage symptoms or behavior that may otherwise result in an incident Yes No NA Yes No NA Ability to self-manage symptoms or behavior that may otherwise result in suspension or termination of services Yes No NA Yes No NA Other symptoms or behaviors that may jeopardize the health and safety of the person or others Yes No NA Yes No NA Other Symptoms or Behaviors: Yes No NA Yes No NA Other Symptoms or Behaviors: Yes No NA Yes No NA Assessment and initial service planning meeting participants: Name Signature Title Date Person Completing Assessment
245d-intensive-support-self-management-assessment-sample-document_tcm1053-297281.docx