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Meet and Greet Questionnaire

 

Instructions

 

DURING THE MEET AND GREET PLEASE DISCUSS THE FOLLOWING INFORMATION WITH THE FAMILY. THE INFORMATION YOU GATHER BY FILLING OUT THIS FORM WILL HELP YOU UNDERSTAND HOW TO MEET THE CLIENT'S NEEDS MOST EFFICIENTLY.

Meet and Greet Date*
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Please input your (provider) first name.
Please input your (provider) last name. 
How did you complete the meet and greet with this client?*
 

Client Personal Information

Please enter information for the client.

Client Presentation Tracking Number(s) can be found in the subject line of the client presentation email. If there is no tracking number(s) please enter the name included in the subject line.
Client Birth Date*
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Client Gender*
Current address where Client resides. 
What are the main cross streets near the client's home?
Who lives in the Client's primary household?*
Choose all that apply.
What school is the client currently attending?

Parent/Guardian Information

The Guardian's information, including the email address, is required to work with the client.
This information is required to set up their SpokeChoice profile. 
The SpokeChoice profile is how the guardian signs off on your timecard in order to track their authorizations and for you to get paid. This is a state requirement.
First and Last Name
Preferred email contact.
Preferred phone number.
Please list your current address
First and Last Name 
Email
Phone Number

Medical Information

Please list all medical diagnoses.
Please list all known allergies, if any:
Does the client have seizures?
Please list all known medications, if any:
Verbal or non-verbal?
Does the client require feeding assistance?
Toileting Assistance*
Is the Client fully toilet trained?
Please list pertinent information about the client's toileting needs here.
Behavioral Information
 
Does the client demonstrate any self-stimulatory behavior(s)?*
(Rocking, hand fidgeting, excessive jumping, repetitive behaviors, etc.)
Does the client demonstrate any self-injurious behavior(s)?*
(Biting, scratching, hand banging, head hitting, etc.)
Does the client demonstrate any aggressive behavior(s)?*
(Hitting, pinching, kicking, biting, etc.)
Does the client wander or run from a safe environment?*
Does the client have difficulty recognizing dangerous situations?*
(Running into the street, playing with sharp objects, etc.)
What is the level of independence in which the client can complete most tasks, whether they are preferred or not preferred?*
Please indicate which best describes the Client.

Request for Support Services

Requested Services*
Select all that apply
Has the client received Respite or Habilitation services through the Department of Developmental Disabilities (DDD) before?*
What is the client's preferred assignment length for services?*
What days does the client wish to receive services?*
Select all that apply. 
Example: 9:00am - 12:00pm or 10 hours a week
Please list any additional services the client is receiving. (Attendant Care, Speech Therapy, Occupational Therapy, Physical Therapy, ABA, etc.)
Service Lines and Programs *
What EE services would the client like to learn more about?  Choose all that apply.
Please list likes, dislikes, and possible triggers.
What do they need from you? Will support be all at home?  
What does providing Respite or Habilitation need look like?
Is there anything else the client's family thinks you should know as a potential provider?