STATUS CHECK – NON-SUPPORTED LIVING INDIVIDUALS
Use this form if you work with an individual who does not receive supported living services from the provider to determine the health, safety, and well-
being of the client and to identify any observed issues and resolutions to these issues. Complete on Intake and Quarterly and submit to the office.
Individual	Date
Staff Name	WSC/Agency
Services (list)
Individual's living arrangements	Home with Parents	Group Home/ALF	Shares Home	Lives Alone	Owns Home	Rents Home
Other living arrangements (explain)
Yes	No	Does the client have a guardian?	Name of Guardian
Yes	No	Does another supported living agency provide services to the individual? If yes, state the agency's name, services, and SLC's name.
Agency Name	SLC Name
Services Provided by Other Agency (list all)
PROBLEMS/ISSUES/RESOLUTIONS
Yes	No	Is there any issue regarding what the client/guardian expects from the provider and what the provider can actually provide? (Describe)

Yes	No	Physical Health and/or Mental Health (emotional/behavioral) Problems? (If yes, explain the problem and how it was resolved)

Yes	No	Safety Problems? (If yes, explain the problem and how it was resolved)

Yes	No	Medication Problems? (If yes, explain the problem and how it was resolved)

Yes	No	Interpersonal Problems? (If yes, explain the problem and how it was resolved)

Yes	No	Maintenance Problems? (If yes, explain the problem and how it was resolved)

Yes	No	Other Problems? (If yes, explain the problem and how it was resolved)

Individual	Signature	Date
Client
Guardian
Staff