Skip to Main Content
NY.gov Portal State Agency Listing Search all of NY.gov
Ann Marie T. Sullivan, M.D., Acting Commissioner
Governor Andrew M. Cuomo

Home and Community Based Services Waiver
and Safety Plan Contract

View Adobe Acrobat Version | Download Adobe Acrobat Reader

These are the things that usually make me most upset:

This is what I do when I start feeling upset:

The best things for me to do to stop feeling upset are:

When I feel upset, the people I would like to talk to or be with are:

When I am upset, I wish people would:  

I agree that I will try my best to do the things that make me feel better, when I first notice that I am starting to feel upset.

Required Signatures
Child:   Date:  
Parent:   Date:  
ICC:   Date:  
Teacher (if school is involved:   Date:  

 Rev.5/10

Comments or questions about the information on this page can be directed to the Home and Community Based Waiver Program.