My Routine and Personal Needs
|Personal Preferences |
|Person Centered Plan Outcome(s) (addressed in this service from the PC ISP Shared Plan): |
| |
|Traits or qualities preferred in those who support the individual: |
| |
|For individuals who do not speak: |
|This is how I communicate “yes”: | |
|This is how I communicate “no”: | |
|Other information about how I communicate: | |
|People who support with intimate needs: |
|List the people (paid and unpaid) who are acceptable to the individual for intimate supports (such as bathing, personal hygiene, feminine care, |
|lifting/transferring/positioning, dressing, restroom): |
|Below are specific preferences when providing supports: |
|Supports |Personal preferences/What’s important to me: |
|Lifting/transferring/positioning: | |
|Eating/meal preparation: | |
|Bathing/showering: | |
|Skin care/personal appearance: | |
|Dressing: | |
|Restroom: | |
|Feminine care: | |
|Home care: | |
|Money management: | |
|Community: | |
|Other: ____________________ | |
|Comments: |
Completed by: ____________________________________ Date completed: __________
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