supported employment community based assessment activities form

LRS SE1-ASUPPORTED EMPLOYMENT COMMUNITY BASED ASSESSMENT ACTIVITIES FORM(Milestone 1)1Consumer: ____________________________________LRS Counselor: ________________________________Vendor: ____________________ Date: ____________Case Number: _________________________________The Activities Summary must be completed and included as the last page of the Narrative AssessmentReport.I. INDIVIDUALS CONTACTED:1. Name: _____________________________________Relationship to Consumer: _______________Date: _________Type of Contact: Phone – Phone #: ____________________________ On-site Visit – Location: ________________________________________________________ Meeting – Location: ________________________________________________________Others Present (if applicable): Name: ________________________________________Relationship to consumer: ______________________________Name: ________________________________________Relationship to consumer: ______________________________2. Name: _____________________________________Relationship to Consumer: _______________Date: _______Type of Contact: Phone – Phone #: ____________________________ On-site Visit – Location: ________________________________________________________ Meeting – Location: ________________________________________________________Others Present (if applicable): Name: ______________________________________________Relationship to consumer: ______________________________Name: ______________________________________________Relationship to consumer: ______________________________3. Name: _____________________________________Relationship to Consumer: _______________Date: _______Type of Contact: Phone – Phone #: ____________________________ On-site Visit – Location: ________________________________________________________ Meeting – Location: ________________________________________________________Others Present (if applicable): Name: ______________________________________________Relationship to consumer: ______________________________Name: ______________________________________________Relationship to consumer: ______________________________

LRS SE1-ASUPPORTED EMPLOYMENT COMMUNITY BASED ASSESSMENT ACTIVITIES FORM(Milestone 1)24. Name: _____________________________________Relationship to Consumer: _______________Date: _______Type of Contact: Phone – Phone #: ____________________________ On-site Visit – Location: ________________________________________________________ Meeting – Location: ________________________________________________________Others Present (if applicable): Name: ______________________________________________Relationship to consumer: ______________________________Name: ______________________________________________Relationship to consumer: ______________________________5. Name: _____________________________________Relationship to Consumer: _______________Date: _______Type of Contact: Phone – Phone #: ____________________________ On-site Visit – Location: ________________________________________________________ Meeting – Location: ________________________________________________________Others Present (if applicable): Name: ______________________________________________Relationship to consumer: ______________________________Name: ______________________________________________Relationship to consumer: ______________________________II.OTHER PLACES/EMPLOYMENT SITES VISITED:1. Name: ________________________________Address: _________________________________________________________________________________________________________________Date: ________ Type of Business: ___________________________________________________2. Name: ________________________________Address: _________________________________________________________________________________________________________________Date: ________ Type of Business: ___________________________________________________3. Name: ________________________________Address: _________________________________________________________________________________________________________________Date: ________ Type of Business: ___________________________________________________III.OTHER COMMENTS/DOCUMENTATION/CONTACTS:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Completed by:______________________________Title:_________________________Date:_______