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INTAKE

By Jeffrey Jackson,2014-08-12 08:36
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INTAKE ...

SET for Life

    INTAKE

    1. What have you accomplished?

     Educational Experience:

     Vocational Experience:

     Volunteer Work:

2. What are your vocational skills, interests and dreams?

     Skills:

     Interests:

     Dreams:

    3. Work related questions:

     Hours/Schedule:

     Location:

     Environment:

     Pay/Benefits:

     Clothing:

    4. Possible barriers to employment:

     “If you were offered a job tomorrow, would you be ready to start?”

     Benefits/Financial:

     Health & Medical Needs:

     Support Systems:

     Living Arrangements:

    Part IV - 9

SET for Life

Equipment Needs Rehab Technology:

Part IV - 10

SET for Life

     Orienting:

     Small area only One room Several rooms Building wide

     Building & ground

     Specific comments: __________________________________________________

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     Independent work rate (no prompts):

     Slow pace Steady/average pace

     Above average/sometimes fast pace Continual fast pace

     Specific comments: __________________________________________________

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     Appearance:

     Unkempt/poor hygiene Neat/clean but clothing unmatched

     Unkempt/clean Neat/clean and clothing matched

     Specific comments: __________________________________________________

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     Communication:

     Uses sounds/gestures Speaks unclearly

     Communicates clearly, intelligible to strangers

     Some sign language Fluent sign language

     Specific comments: __________________________________________________

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SET for Life

     Acts/speaks aggressively:

     Hourly Daily Weekly Monthly Never

     Specific comments: __________________________________________________

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     Appropriate social interactions:

     Rarely interacts appropriately Initiates social interactions infrequently

     Polite, responses appropriate Initiates social interactions frequently

     Specific comments: __________________________________________________

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     Unusual behavior:

     Many unusual behaviors Few unusual behaviors

     No unusual behaviors

     Specific comments: __________________________________________________

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     Discrimination skills:

     Can’t distinguish between work supplies Distinguishes between work supplies

     Distinguishes between work supplies with an external cue

     Specific comments: __________________________________________________

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     Time awareness:

     Unaware of time and clock function Can tell time to the hour

     Identifies breaks and lunch Can tell time in hours and minutes

     Specific comments: __________________________________________________

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SET for Life

    Travel Skills (check yes or no for each item):

    Requires bus training Yes No

Uses bus independently/no transfer Yes No

Uses bus independently/makes transfer Yes No

Able to make own travel arrangements Yes No

     Specific comments: __________________________________________________

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Other:

5. TO DO’s (meetings, areas of exploration, phone calls, etc.)

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    Additional comments: ________________________________________________

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Check for the following release forms:

     SSA APA MH DVR TVR DD

     Guardian Other

     Alaska Housing Authority Resource Team

     Copy of Social Security Card Copy of ID Card

    Part IV - 13

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