FUNCTIONAL COMMUNITY ASSESSMENT	Date
Client	Meeting Date with Client
Staff	Meeting Date with WSC
Intake?	Yes	No	Start Date	Qtr 3/AR Months Covered
Complete this when a new client starts (Intake) and every year thereafter during the 3rd Quarter, before completing the Person-Centered Planning. From your observations and discussions with the individual and circle of support, determine areas in which the individual needs support from staff or others. Use the Functional Community Assessment Categories with examples provided and for each category identify areas that the individual generally requires substantial physical assistance and/or constant supervision or moderate frequent support/assistance. Do NOT include areas where the individual requires minimal verbal prompts (difficult steps, to start and end activity) or no assistance (completes activity independently). If the client/guardian and circle of support agree, some or all of the areas that he needs to work on can be included as goals on his Annual Report for his upcoming Support Plan.
Safety/Emergencies

Health/Sexuality

Consumer Skills

Household Management

Money Management

Meal Preparation

Self Care/Hygiene

Clothing Care

Communication

Community Mobility

Interpersonal Relationships

Leisure Time/Activities/ Interactions
Positive Characteristics

Limiting Factors

Accessing Resources

In Home Activities

Community Activities

Things That Do Not Work: Identify behaviors and situations that create frustration, depression, excessive boredom, anger, other negative emotions or that trigger negative emotions or behaviors.

Things That Do Work: Identify situations that create satisfaction, happiness, creativity, initiative, energy or that trigger positive emotions or behaviors.