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Screening Questionnaire
Resident Name
*
Why are you looking for placement? Who currently lives in home/ Cilla?
*
Has he attended school or day program?
Diet/Eating concerns?
*
Bathing habits, issues/concerns? Transfer status?
*
Sleeping habits, issues/concerns?
*
Medical issues/concerns? Go out and do well with appointments? Take pills with or without problems? Past procedures/ surgeries?
*
Hobbies? Activities? Like to go out?
*
Toileting habits? Issues/concerns?
*
Sexual issues/concerns?
*
Any issues/concerns with socializing with others? Like large groups? Quiet environments?
*
Do they have any separation issues/concerns?
*
Communication?
*
Behaviors
Types?
*
Last incident of behavior?
*
How often do they occur?
*
Triggers?
*
Destructive?
*
Severity?
*
De-escalated?
*
Are they involved with any specialty team for behaviors?
Elopement issues?
*
PICA?
*
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