Have you ever struggled to create a service plan for a client? If so, you're not alone. Luckily, there's a helpful form that can make the process much easier. The Individualized Service Plan Form is designed to help service providers develop tailored service plans that meet the unique needs of their clients. The form can be used to document services provided, objectives achieved, and progress made. It's also a great tool for tracking client involvement and participation in goal setting. Simply fill out the form each time you work with a client, and you'll have an up-to-date record of their individualized service plan.
The listing includes information regarding the individualized service plan form. You can study it just before writing the gaps.
Question | Answer |
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Form Name | Individualized Service Plan Form |
Form Length | 5 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 1 min 15 sec |
Other names | individualized service plan form, individual service plan forms, service plan forms for assisted living, blank isp forms |
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Assisted Living Individualized Service Plan (ISP) |
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Resident Name: |
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Female Male |
Date: |
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For: Initial Six months Other ___________ |
Note: Services to be provided and by whom: Any additional information or change of service on this ISP must be indicated in bold type, capital letters, or by using a different color ink and dated. Indicate the reason for any change in service in the last column, and the date of the change.
Key: N/A = Not Applicable, RA = Resident Aide, N = Nurse, P = Physician, L = Lab Tech, T = Therapist, O = Other
Part 1 – Care Needs
Activity – Check all |
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Services to be provided: |
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Frequency |
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Changes/Comments |
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Whom |
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Medical - Nursing |
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Lab Test |
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Pacemaker |
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Dialysis |
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Skilled Nursing, |
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Injection Insulin |
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Treatments &/or |
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Education |
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Other – Type __________________ |
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Dressing |
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Other ________________________ |
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Specialists (eg |
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Specify________________________________ |
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podiatrist, |
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chiropractor) |
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Medical Equipment |
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Independent |
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Type _______________ |
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1+ Assist (requires more than |
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intermittent assistance with equipment |
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EALR required) |
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Pain Management |
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Other |
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health prevention |
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other – specify____________________ |
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Rehabilitation
PT
OT
Speech Therapy
Other: ____________________
Nutritional
Diet – Meal Assist
Regular NAS NCS
Chopped as needed Soft
Dietary Supplement
Specify: _____________________
Meals
Snacks
Chewing Difficulty
Swallowing Difficulty
Other: _______________
Resident Name: ________________________________________ Date: ____________ |
ISP Page 2 of 5 |
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Activity – Check all |
Services to be provided: |
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Frequency |
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Changes/Comments |
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applicable |
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Whom |
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Fluid Restrictions/ |
None |
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Encouragement |
Dietary Supplements _______________ |
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Other Specify: __________________ |
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Functional |
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Personal Hygiene |
Independent |
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Shower |
Bath |
Equipment |
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Hearing Aide: |
R |
L |
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Eyeglasses Reading Always |
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Hair: Shampoo Grooming Shave |
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Teeth Care Denture Care |
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Nail Care |
Foot Care |
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Continence |
Independent |
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Assist with bathroom |
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Assist with protective garment change |
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Ostomy Care |
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Chronic unmanaged incontinence |
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(chronically unwilling or unable to |
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participate, with help from staff, so that |
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cleanliness and sanitation can be |
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maintained - EALR required) |
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Skin Care |
None |
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Location & Type: _________________ |
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Dressing |
Independent |
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Coordinate Upper Lower |
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Other _________________________ |
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Medications |
Self Assist |
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Transfer |
Independent |
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1+ Assist (chronically chairfast and/or |
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chronically needs one person assist to |
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transfer – EALR required) |
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Mobility |
Independent |
Walker Cane |
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Wheelchair |
Crutches |
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Escort: _______________________ |
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1+ Assist (chronically needs one person |
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to assist to walk or to climb/descend stairs- |
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EALR required) |
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Falls Risk Reduction |
No Known History |
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Other: __________________________ |
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Respiratory Therapy |
None |
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& Oxygen |
Type: _________________________ |
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Equipment |
None |
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Prosthesis |
Braces |
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Other __________________________ |
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Resident Name: ________________________________________ |
Date: ____________ |
ISP Page 3 of 5 |
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Activity – Check all |
Services to be provided: |
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Frequency |
By |
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Changes/Comments |
applicable |
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Whom |
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Cognitive |
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Orientation |
N/A Remind Cue Supervise |
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Accompany |
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Specialized Services |
N/A |
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Dementia Care, Secured Unit (requires |
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SNALR) |
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Environmental modifications |
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Supervision/Monitoring |
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Sensory |
None |
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Hearing Vision Speech |
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Other: ________________________ |
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Mental Health |
Diagnosis: _____________________ |
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Treatment Required ___Yes ___No |
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Substance Abuse |
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Coordination with SA |
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provider__________________________ |
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Social |
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Education & |
Desire for continued or future education: |
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Employment |
Yes No |
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If yes, specify: ___________________ |
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Desire to work or volunteer |
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Yes No |
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If yes, specify: __________________ |
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Intellectual |
Desire for new or continued intellectual |
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activity |
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Yes No |
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If yes, specify: ___________________ |
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Recreational |
Desire for new or continued recreational |
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activity |
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No Yes, Specify: _______________ |
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Need assistance of ALR staff |
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Specify: ______________________ |
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Spiritual |
Desire for new or continued spiritual activity |
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No Yes, Specify: ________________ |
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Need assistance of ALR staff |
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Specify: _________________________ |
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Cultural |
Desire for new or continued cultural activity |
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No Yes, Specify: ________________ |
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Need assistance of ALR staff |
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Specify: _________________________ |
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Financial |
Assistance with access to financial benfits |
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(i.e. Medicare, Medicaid, Social Security, |
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Veteran’s Admin., Pensions, etc.) |
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Managed Independently |
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Assistance of family, resident rep. or |
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legal rep. Specify: __________________ |
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Need assistance of ALR staff |
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Specify: _________________________ |
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Resident Name: ________________________________________ |
Date: ____________ |
ISP Page 4 of 5 |
Other
Comments:
Print Name, Title and Organization of Individuals Participating
Resident
Resident’s Representative
Resident’s Legal Representative (if applicable)
ALR Provider’s Representative
Was the Resident’s Primary Physician Consulted? |
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Yes |
Indicate physician’s name and date: |
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_________________ |
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No |
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__________________________________________ |
________________________________________ |
__________________ |
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Home Care Services Agency Rep. Signature |
ALR Provider’s Representative Signature |
Date |
(if applicable)
Documentation of ISP Review: For
areas: Communication/Dental/Vision/Hearing; Customary Routine, Continence Status/Management, Physical Function, Cognitive Impairment Screen, and Admission Decision.
I am confirming the ISP services as listed above, including any changes that have been made since the last review.
I have reviewed the ISP services as listed above and recommend the following change(s) in service: __________
______________________________________________________________________________________________
_______________________________ |
______________________ |
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______________________ |
Name |
Title |
Date |
Signature |
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Documentation of ISP Review: For
areas: Communication/Dental/Vision/Hearing; Customary Routine, Continence Status/Management, Physical Function, Cognitive Impairment Screen, and Admission Decision.
I am confirming the ISP services as listed above, including any changes that have been made since the last review.
I have reviewed the ISP services as listed above and recommend the following change(s) in service: __________
______________________________________________________________________________________________
_______________________________ |
______________________ |
____________ |
______________________ |
Name |
Title |
Date |
Signature |
Attach Documentation of additional ISP Reviews as Necessary
Resident Name: ________________________________________ |
Date: ____________ |
ISP Page 5 of 5 |
Assisted Living Individualized Service Plan
Addendum for Enriched Housing Program/Assisted Living Residences
(If applicable)
Note: Services to be provided and by whom: Any additional information or change of service on this ISP must be indicated in bold type, capital letters, or by using a different color ink and dated. Indicate the reason for any change in
service in the last column, and the date of the change.
Key: N/A = Not Applicable, RA = Resident Aide, N = Nurse, P = Physician, L = Lab Tech, T = Therapist, O = Other
The following information pertains to additional tasks not included on the ISP relating to the enriched housing program functional assessment
Activity
Services to be provided:
Frequency
By
Whom
Changes/Comments
Instrumental |
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Activities of Daily |
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Living |
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Transportation |
independent, drives own car or accesses |
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transportation on own & chooses to do so |
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wants or needs someone to drive them, |
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but does not require an escort |
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must be accompanied by an escort |
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requires special transportation |
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specify ___________________ |
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Laundry |
is able & chooses to do own laundry |
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is able & chooses to do light laundry, but |
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wants/needs assistance with heavy laundry |
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needs or chooses ALR to do all laundry |
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Housekeeping |
is able & chooses to do all housekeeping |
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tasks in room/apartment |
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is able & chooses to do light |
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housekeeping, but wants/needs assistance |
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with heavier cleaning tasks |
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Specify _________________________ |
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needs or chooses ALR to do all |
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housekeeping |
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Shopping |
is able & chooses to shop on their own & |
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carry or transport packages on their own |
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is able & chooses to do light shopping on |
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their own, but wants/needs assistance with |
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major shopping |
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Specify _________________________ |
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needs or chooses ALR staff or other |
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person (i.e. family member) to do all of their |
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shopping |
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Ability to use |
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telephone |
and answers calls without assistance |
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has specially adapted phone and dials |
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numbers and answers calls without |
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assistance |
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chooses or needs ALR staff to help them |
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make calls or make the calls on their behalf |
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