DADS or HHSC Form - The Texas Department of Aging and ...
DADS or HHSC Form - The Texas Department of Aging and ...
DADS or HHSC Form - The Texas Department of Aging and ...
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F<strong>or</strong>m 3596<br />
Page 6, 12-2013<br />
4. Day Activity<br />
Day Activity <strong>and</strong> Health Services (DAHS) Prevocational Employment Employment Assistance Supp<strong>or</strong>ted Employment<br />
Other (specify):<br />
Monday Tuesday Wednesday Thursday Friday Saturday Sunday<br />
Comments<br />
Weekly Total Day Activity Hours:<br />
5. Education<br />
School Home Schooled Higher Education Other (specify):<br />
Monday Tuesday Wednesday Thursday Friday Saturday Sunday<br />
Comments<br />
Weekly Total Education Hours:<br />
III. Non-CLASS Caregiver Supp<strong>or</strong>t<br />
1. Living Arrangement<br />
Who does the individual live with? Alone Parent(s) Spouse/significant Other Caregiver Other (specify):<br />
Provide relationship, age <strong>and</strong> presence <strong>of</strong> a disability f<strong>or</strong> all who reside in the same household as the individual:<br />
Relationship Age Disability Relationship Age Disability<br />
Yes No Yes No<br />
Yes No Yes No<br />
Yes No Yes No<br />
2. Caregiver Schedule<br />
Name:<br />
Relationship to Individual:<br />
Caregiver Supp<strong>or</strong>t Monday Tuesday Wednesday Thursday Friday Saturday Sunday<br />
W<strong>or</strong>k Schedule<br />
Unpaid Supp<strong>or</strong>t Supervision<br />
Provided to Individual<br />
3. Caregiver Schedule<br />
Name:<br />
Relationship to Individual:<br />
Caregiver Supp<strong>or</strong>t Monday Tuesday Wednesday Thursday Friday Saturday Sunday<br />
W<strong>or</strong>k Schedule<br />
Unpaid Supp<strong>or</strong>t Supervision<br />
Provided to Individual
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