STAFFING AUTHORIZATION

_____________________________________________________

(Name of Individual)

Services provided to you by Life's New Beginnings, Inc., include:

Supported Living Coaching (SLC)

Personal Support-Day (Live-In)

Personal Support-Quarter

Life Skill Development 1 (Companion)

Other (specify) ______________________________________

There are qualified staff members who will assist you with progress on your support plan goals as well as with skills to meet your daily needs, to improve your daily living skills, to assist you with medical, dental another health services, and to enrich your personal and community life. There may be more than one staff person providing different services to you. For example, you may have one coach and one personal care assistant and one non residential support services staff. You may also have more than one staff person providing the same service. For example, you may have two coaches or two or more In Home Support Staff persons working with you.

In general, you will have one main staff person working with you to whom you may refer all of your questions or problems. This person will help coordinate services with you. At times, due to emergencies, split tasks, vacations, or other reasons, your main staff may be unavailable and may ask another qualified staff person to assume his or her responsibilities.

Service	Main Staff Name	Contact Number

Service	Staff Name	Contact Number

Go over the information with the individual on Intake, obtain signatures and submit to the Program Administrator. For Annual and Quarterly Reviews, use this information for reference only and have the client sign the Topics form as proof the client received this information. Provide a copy if the client wants one.
Individual	Signature	Date
Individual
Guardian/Representative
Staff