Individuals (add multiples names seperated by a coma ',')

1. My discussed responsibilities for the upcoming week are:

2. On goings in the household that I am satisfied with (ex.Housemates, Food Menu, Environment, Procedures etc.):

3. On goings in the household in which I would like to see changes made:

4. My accomplishments for the past week:

5. Things I need:

1. What i did at School/Work this week:

2. Things in School/Work that I am satisfied with (ex. Transportation, Co-workers/Classmates, Curriculam/Tasks, Environment, Supervisors etc.):

3. Things in School/work that I have concerns about:

1. My Interest and Preferences are:

2. Activities I would like to participate in this upcoming week/weekend:

3. What activities did I participate in this past week:

Additional Comments (to be filled out by the Staff if needed):

Follow Up Action (to be filled out by Coordinator)

Staff Name