Home and Community Based Services Waiver Group Progress Notes
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Complete all fields:
A) Client’s name:
B) Client ID #:
C) Client’s date of birth:
D) Contact Date:
E) Start Time:
F) End Time:
G) Duration:
H) Check Waiver group service type: RS ____ SB ____ FSS ____:
Waiver child: ______
Waiver child’s parent(s)/primary caregiver(s) _________
Names: ______________________________________________________________
Waiver child’s sibling ______ Sibling name(s): ______________________
_________________________________________________________________
J) Indicate participant to worker ratio for the group: ________
1. Identify goal number(s) and objective letter(s) that apply to this group contact: ________________________
2. Flexible Service Dollars: Amount spent: $________
Purpose of expenditure (on what was the money spent):
3. Summarize the contact for the Waiver child and/or each of his/her siblings and/or caregivers including a description for each of progress towards the Waiver child’s identified goal and objective:
4. Signature: Title: Date of Entry:
Comments or questions about the information on this page can be directed to the Home and Community Based Waiver Program.