Support Coordination Contact Documentation (SCD)
Support Coordinator's Email
*
example@example.com
Participant initials:
*
Contact Type
Waiver Type
*
Children's choice
Support Waiver
ROW
NOW
Participant
*
Service Log
SC ID or Name
*
Date
*
/
Month
/
Day
Year
Date
Begin Time
*
If visit is face-to-face do not write begin and end time, instead write EVV
End Time
*
If visit is face-to-face do not write begin and end time, instead write EVV
Place of Service
*
Please Select
02 Place of Residence
09 Day program or ADHC facility
10 Mental Health Clinic
12 School
13 SC Agency
14 Jail or Correctional Facility
15 Day Care or nursery school
16 OT, PT, Speech Therapist's office
18 Early Intervention Provider
19 Service provider's place of buisness
21 Hospital
22 Medical/Public Health Clinic
23 ICF/DD
24 Nursing Facility
99 Other community location
Type of Contact
*
Please Select
1 In person
2 Telephone
3 Written
6 Documentation
8 Telehealth
Service Activity
*
Service Participants
*
Monthly Monitoring
Monthly Remediation
Annual Monitoring
Annual Remediation
Name of individuals providing response to questions (Check all tha apply)
Relationship of person providing reponse
*
Participant
Responsible Representative
Legally Responsible Representative
Other, write relationship below
Name of Participant
Name of Responsible Representative
Name of Legally Responsible Representative
Name of other team member
C: Support Coordination Actions
Support Coordination Actions: Check all that apply, provide details in D (Comments)
*
Resolution of Accessing POC services
Continue to Monitor
Revise Emergency Plan
Revise Backup Staffing Plan
POC Revision
FOC offered
Referral for Service (Specify in D)
Other
D Comments
0/1000
E. Signatures:
Note: Participant/Responsible/Legal Responsible Representative signatures are required at quarterly visits or other face to face visits only
See attachment for additional documentation/signatures (this might include a sign in sheet with all team emmbers in attendance signatures.)
*
Check here
Participant/Responsible representative/Legally responsible Representative Signature
*
Date
*
/
Month
/
Day
Year
Date
Support Coordination Signature
*
Title of signature above
Please Select
Support Coordinator
SC Supervisor
Program Director
Trainer
Nurse
Assistant Vice Prisident
Vice Preisdent
Printed name of above Signature
Date
*
/
Month
/
Day
Year
Date
Page 2: Notes Page
Participant Name
*
Date
*
/
Month
/
Day
Year
Date
Additional Notes:
*
0/2500
Page 3: Signature Page
Meeting Type
*
Individualized Team Meeting
Quarterly Meeting
Annual Plan of Care Meeting
Waiver Type
*
NOW
Supports
ROW
CC
Signature
*
Title and Agency affiliation of signture above
*
Date
*
-
Month
-
Day
Year
Date
Signature
*
Title and Agency affiliation of signture above
*
Date
*
-
Month
-
Day
Year
Date
Signature
Title and Agency affiliation of signture above
Date
-
Month
-
Day
Year
Date
Signature
Title and Agency affiliation of signture above
Date
-
Month
-
Day
Year
Date
Signature
Title and Agency affiliation of signture above
Date
-
Month
-
Day
Year
Date
Signature
Title and Agency affiliation of signture above
Date
-
Month
-
Day
Year
Date
Additional Signatures
Participant Name
Date
/
Month
/
Day
Year
Date
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