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You will need Word Perfect 2000 or above for some forms. If you do not have that software, you can purchase it from WordPerfect Corel. For the APD files, you will need to go to the APD Cares website and you will need Microsoft Word, version 2003 or above or Adobe Acrobat Reader to download the forms.  If you do not have Microsoft Word, you can purchase that software from Microsoft. If you do not have Adobe Reader, you can download that software from http://www.adobe.com/reader.

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NOTE: When using the WordPerfect forms, do NOT change fonts, margins, or other formatting because your forms will not print properly. Use VIEW-ZOOM when typing to enlarge what you see on the screen - this will not change the printing.

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You can click on the >><< to find out more information about some areas (for example: Topics/Charts Reference). Remember to close the popup window after use.
CLIENT FORMS
CLIENT REVIEW FORMS
The chart shows which forms are needed for each review. Areas marked with an X are not required for the specified review. Make 1 copy of each required review item and 2 copies of each item with a ■, as needed. Items with ■ (numbered 1-13) must be provided to the WSC. Review areas with the individual BEFORE the WSC meeting.
REVIEW FORMS QTR 3/ANNUAL QTR 4 QTR 1 QTR 2 INTAKE
1 ■Checklist Use as a guide for each review NEW 02-17    
2 ■Topics/Charts Use with forms in >><< Topics/Charts Reference information (all forms are signed on Intake)    
    Functional Community Assessment Use with FCA Categories from Reference Info   X X X  
    Abuse Topics Also in Reference Info   X X X  
    Client-Guardian Release Also in Reference Info   X X X  
   ■Financial Authorization Also in Reference Info NEW 06-16   X X X  
3 ■IFP and Attachment See OTHER FORMS for Subsidy Request    
4 ■Status/Medical Update    
5 ■Health, Safety, & Housing Checklist    
6 ■Person-Centered Planning Use to pre-plan goals and services BEFORE the annual review and support plan meeting   X X X  
7 ■Quarterly Summary (Qtr 1, 2, 4) X X 
8 ■Annual Summary (Qtr 1, 2, 3 + previous Qtr 4 SP + projected goals)   X X X X 
9 ■Support Plan Update Use to update the SP if goals are not what the client specified, 4th Quarter (If Needed) X X X X 
10 ■Implementation Plan (Complete within 30 days of receiving SP) IP Signature Page & IP Goal Action Plan OR Transition Plan Use if no SP is provided (Attach Disaster Preparedness) New Sig Page 02-17 X  X X  
11 ■Satisfaction Survey   X X X X 
WSC Monitoring Tool (Receive from WSC)   X 
Client Self-Assessment Survey   X X X X 
Client Demographics/Health History All Clients   X X X  
Medication Agreement (must be signed by client/guardian) All Clients   X X X  
Medication Authorization - APD (must be signed by physician) All Clients   X X X  
Informed Consent - APD (1 for each staff assisting with medications) Med Clients Only   X X X  
PRN/OTC Authorization (must be signed by physician) Med Clients Only   X X X  
Provider-Client Schedule A mutually agreed on schedule for staff and client   X X X  
Day Routine (If Applicable)   X X X  
Non-SLP Status Check NEW 08-15    
Client Intake Interview and SLP Contract X X X X  
Intake Release - Health, Dental, Transportation X X X X  
Information Acquisition/Release (Only As Needed)    
Promotion/Training Release (Only As Needed)    
Medicaid/FS/SS/Payee Information   X X X  
Transition Report (Intake/Exit)    
Medical Exam or Treatment Log (As Needed-Health Appointments)    
Learning Experiences (Use with Instructions at minimum 1x month)    
12 ■DISASTER PREPAREDNESS (Intake; every April; Attach to IP) New 02-17 X X X  
13 ■TRANSITIONAL GUIDE (Only If moving)
     
MEDICATION, HEALTH, & REFERENCE FORMS
MEDICATION INFORMATION
(Keep in home MAR) Med Clients Only 		HEALTH INFORMATION >><<TOPICS/CHARTS REFERENCE Use with Topics/Charts form. Sign at Intake, review Quarterly. ●= Review& sign Annually with Topics/Charts Form. ■= Provide copy to WSC Annually. Charts must be available to client. NEW 06-16
Medication Admin Record (MAR) Seizure Report Rights, Resp, Choice NEW 6-16 and Chart Circle of Support
New & Refill Medications Advanced Directives/Living Will Info & forms Reporting Measures and Chart Key Authorization
Medication Notes >><<Do Not Resuscitate Order - Form 1896 NEW 01-17 HIPAA Staffing Authorization
3 Dose Tracking Do Not Resuscitate - Information Due Process ●■Financial Authorization NEW 06-16
Controlled Subs Count - APD Safety Plan (If Needed, done by WSC) ●Abuse Topics Grievance Form (Only If Needed)
Medication Error Report - APD   Fire, Safety, Emergency Procedures FCA Categories-with ●FCA
Med Destruction Report - APD   Bill of Rights ●Client-Guardian Release
Offsite Medications - APD      
Medication Information (not required)        
       
       
MISCELLANEOUS FORMS
OTHER FORMS SAMPLES PRINT FORMS SERVICE DESCRIPTIONS TBD
Expense Log Service Log Sample   IFP Supported Living Cocah
Service Log See Below IFP Sample IFP Attachment Personal Supports - QTR
Service Log Instructions NEW 02-14 IFP Attachement Sample Person-Centered Planning Personal Supports - DAY
Learning Experiences PCP Sample Quarterly Summary Life Skills Development 1
Learning Experiences Instructions Quarterly Summary Sample Annual Summary  
Medication Error Report - APD Annual Summary Sample IP Goal Action Plan  
Med Destruction Report - APD Status/Medical Check Sample Service Log PS DAY PRINT NEW 02-14 NEW 02-17  
Off-site Medications - APD   Day Routine  
>><< Incident Report - APD NEW 06-16   Transition Plan  
Staff Self-Assessment   Learning Experiences    
PS-DAY Service Log NEW 1-14 NEW 02-17   Transition Report (Intake/Exit)    
Service Log (SLC, PS-Qtr, LSD) NEW 1-14 NEW 02-17   IP Signature Page    
  Service Log SLC, PS-Qtr, LSD PRINT NEW 02-14 NEW 02-17  
>><< In-Home Subsidy Request NEW 10-16
-- APD-IFP-Subsidy Request.xlsx (or use the IFP.wpd)
-- APD-Subsidy.pdf -- (Appendix II and III)
For your information:
-- APD-SubsidyGuidelines.pdf
-- 393.0695 Provision of in-home subsidies.wpd		   Service Log SLC, PS-Qtr, LSD MSWORD FORMAT NEW 02-14 NEW 02-17 Note - check with supervisor for codes

Service Log PS-DAY MS WORD FORMAT NEW 02-14 NEW 02-17 		 
       
       
TRAINING ACTIVITIES - SUGGESTIONS (*Optional)
Emergency Situations Practice - ideas        
       
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