Employment and Community First CHOICES - Service Log ...



Employment and Community First CHOICES Service Log: Integrated Employment Path Services/Job Coaching/ILS/CISSThis report template is password protected and changes to the format are not permitted, with the exception of the cell in which you type your response and adjusting row height. Please provide the required information in the blue highlighted boxes. If you need more room in a cell, you are able to widen the row height so all information can be viewed. All report templates must be typed or they will not be accepted.ECF Member InformationName: FORMTEXT ?????Date of Birth: FORMTEXT ?????Support Coordinator: FORMTEXT ?????ECF Region: FORMDROPDOWN Member ID: FORMTEXT ?????Member Address: FORMTEXT ?????Provider InformationAgency: FORMTEXT ?????Direct Support Professional (if more than one person, list all names): FORMTEXT ?????Supervisor to Direct Support Professional: FORMTEXT ?????DSP Cell Phone: FORMTEXT ?????Email: FORMTEXT ?????Date of Authorization for Discovery Service Received: FORMTEXT ?????Person-Centered Goals for Service (This should be updated as goals change. If a goal is reached during the reporting period, please include)Service Provided CISS ?ILS ?Path Services ?Job Coaching ?Goal 1 FORMTEXT ?????Goal 2 FORMTEXT ?????Goal 3 FORMTEXT ????? Goal 4 FORMTEXT ?????Goal 5 FORMTEXT ?????Additional Goals: FORMTEXT ?????Service LogDate Reporting Period Started: Date Reporting Period Ended: Complete a separate line for each distinct Exploration activity.Date of ServiceActivity and LocationInclude details on all activities and the connection to the individual’s goalsTime Spent Completing Activity (including travel time with member)Goal Addressed During This ActivityStaff Miles Driven (during travel with and without the member) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Outcomes of ServiceQuestionsYesNoIf Yes, please name goal and supporting information. List all goals that apply.1. Was progress made on any goals? FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????2. Were there barriers that prevented progress in reaching goals (e.g. missed appointments, family stressors or change of environment)? FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Next StepsWhat are the next steps for this member?1. FORMTEXT ?????2. FORMTEXT ?????3. FORMTEXT ?????Date Submitted to BlueCare: FORMTEXT ?????Name of Exploration Facilitator Who Authored This Report: FORMTEXT ?????Signature of Member/Representative Verifying Service: Signature of Direct Support Professional Who Authored This Report: Report Received by (Name): Report Reviewed for Adequacy and Approved by (Name): Date Report Approved **Please submit reports to Support Coordinator** ................
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