| DocumentDate |
{hm_date} |
| Location |
{hm_location} |
| Coordinator |
{hm_coordinator} |
| Individuals |
{hm_individuals} |
|
1. My discussed responsibilities for the upcoming week are:
|
{hm_h_my_discussion}
|
|
2. On goings in the household that I am satisfied with (Ex.Housemates, Food Menu, Environment, Procedure etc.)
|
{hm_h_ongoing1}
|
|
3. On goings in the household in which I would like to see changes made:
|
{hm_h_ongoing2}
|
|
4. My accomplishments for the past week:
|
{hm_h_my_accomplishments}
|
|
5. Things I need:
|
{hm_h_things}
|
 |
At Work/School..... |
|
|
1. What I did at SChool/Work this week:
|
{hm_w_what1}
|
|
2. Things in School/Work that I am satisfied with (ex.Transportation, Co-Workers/Classmates, Curriculum,/Tasks, Environment, Supervisors etc.):
|
{hm_w_things1}
|
|
3. Things in School/Work that I have concerns about:
|
{hm_w_things2}
|
|
In the Community..... |
|
|
1. My Interest and Preferences are:
|
{hm_c_my_interest}
|
|
2. Activities I would like to participate in thsi upcoming week/weekend:
|
{hm_c_activities}
|
|
3. What Activities did I participate in this past week:
|
{hm_c_what_activities}
|
|
Additional Comments (To be filled out by Staff if needed):
|
{hm_addl_comments}
|
|
Follow up Action (To be filled out by Coordinator):
|
{hm_follow_up}
|
| Staff Name |
{hm_staff_name} |
| No records |
|
{Page_Number} of {Total_Pages}
