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 No No Risk of Falling NA NA Yes Yes No No Mobility NA NA Yes Yes No No Regulating Water NA NA Temperature Yes Yes No No Community Survival Skills NA NA Yes Yes No No Water Safety Skills NA NA Yes Yes No No Sensory Disabilities NA NA Other Personal Safety Yes Yes No No Needs: NA NA
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? Risk of Falling Yes No NA Yes No NA Mobility Yes No NA Yes No NA Regulating Water Temperature Yes No NA Yes No NA Community Survival Skills Yes No NA Yes No NA Water Safety Skills Yes No NA Yes No NA Sensory Disabilities Yes No NA Yes No NA Other Personal Safety Needs: Yes No NA Yes No NA
245d-intensive-support-self-management-assessment-sample-document_tcm1053-297281.docx