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?*

Behaviors