Personal Care Assistance Service Support Plan
Sheltered Workshop: ____________________________________________________
Employee’s Name: _____________________________________________________
Employee’s SSN: _______________________________________________________
List of who attended the individual’s personal care assistance meeting:
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Indicate documentation clearly stating the need for personal care support:
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Is a Person Centered Plan Available - Yes No
(Attach copy of all documentation supporting need to this plan.)
1) What Personal Care Assistance/support is required for the consumer to be successfully
employed?
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