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Department of Mental Health and Addiction ServicesFUNCTIONAL ASSESSMENT- Learning Inventory of Skills Training (L.I.S.T.)

Client Name: MPI:

InstructionsAssessment: The assessment should be conducted by someone who knows the client well and in conjunction with the client. It should be as demonstrative as possible and the assessor should ask questions that elicit demonstrative answers (versus “yes” or “no” answers). Each domain can be assessed independently and only as applicable to the client. Annually assess, at a minimum, 10 domains clinically relevant. On Plan of Care identify 2-3 skill building domains that the client is interested in working on in support of their recovery life goals. Within 30 days prior to Plan of Care reassess the 2-3 active domains to inform the Plan of Care development.

Scoring: Each domain has a “minimum” number of skills in each level (Basic, Intermediate, Advanced) that the client must know before moving on to assess the next level. The client is “placed” in the skill level of the domain in which they know the minimum number of skills. For example, in the “Basic” category of the Money Management domain, the client must know 3 of 5 skills in order to move on to assess their skills in the “Intermediate” category. If they only know 2 of the 5 skills, they are considered “Pre-Basic” and the assessment of money management skills would end there. If they know 3 or more of the 5, the assessor moves on to the “Intermediate” category and begins assessing those skills. In the “Intermediate” category the client must know 5 of the 6 items. If they only know 4 (or less) of the 6 items, they are rated as “Basic” and so on. In order to be scored as “Independent” the client should know at least the minimum number of required skills in all three skill levels (Basic, Intermediate, and Advanced).

Cover Sheet (must be completed)Client’s Name:

Person Completing Assessment/Title:

Date of Assessment:

Assessment Type: Initial Review Annual

MPI:

DOB:

DMHAS LMHA/PNP ( in WITS):

Level of Care/Program Type (in WITS):

Domain Level of Skill AttainmentNot

AssessedPre-

BasicBasic Intermediate Advanced Independent Applies

Skill1-Never

2-Sometimes3-Always

Include in Plan of Care(Yes/No)

A. Money Management B. Food Management C. Personal Appearance & Hygiene D. Home Management E. Housing F. Transportation G. Emergency & Safety Skills H. Health & Wellness I. Educational Planning J. Job Seeking Skills K. Job Maintenance Skills L. Knowledge of Community Resources M. Interpersonal Skills N. Legal Skills O. Coping Skills P. Anger Management Q. Relationships R. Pregnancy Prevention S. Parenting and Childcare T. Medication Management

Client’s top three priority domains: (Include in Plan of Care)

1. 2. 3. Integrated Summary (Identify strengths and barriers)Last Updated 8/25/2015 9:49:00 AM of 22

Department of Mental Health and Addiction ServicesFUNCTIONAL ASSESSMENT - Learning Inventory of Skills Training (L.I.S.T.)

Client Name: MPI:

Clinician Signature: Date: Time:

Last Updated 8/25/2015 9:49:00 AM of 22


Client Name: MPI: A. Money Management:Basic- Must know 3 of 5 to advance to the next level of accomplishment

Knows values of coins/currency.Knows how to make a transaction at a store and count change correctlyUnderstands the difference between “luxuries” and “necessities” in food, transportation, clothing, and housing.Understands the difference between “sale price” & “regular price”Knows at least one way to save money on purchases (e.g. discount stores, thrift stores, generic vs. brand name)

Intermediate- Must know 5 of 8 to advance to the next level of accomplishmentKnows how to open a checking or savings accountKnows how to write checks/make withdrawals & depositsKnows how to use an ATM machine to make withdrawals & depositsKnows how to record banking transactionsKnows how to budget for a week (shows some understanding of the concept of saving)Understands the difference between gross wage and take home pay; and understands concepts such as FICA, Federal tax, and other payroll deductionsKnows the difference between ATM, debit card and credit cardKnows how to use a calculator to perform simple math equations

Advanced- Must know 8 of 10 to be rated as advancedKnows how to make out a monthly budget covering regular expenses for independent livingKnows how to read monthly bank statements, compare balances, make adjustments as necessaryKnows how to read bills (utility, loan, credit card, etc.)Knows how and when to pay billsKnows how to comparison shop (e.g. unit pricing, multi store shopping, etc.)Knows how to modify a budget for “unexpected” emergenciesUnderstands how buying on credit, loans, interest, and late payment penalties (credit cards, etc.) affect credit scoresKnow how to balance a checking accountKnows how to create a savings planKnows how to file a basic tax return with or without professional tax preparation assistance

Stage of Change

Pre-contemplative Contemplation Preparation Action Maintenance

Staff/Client Comments:(Include reason for deferral, if appropriate)

Clinician Name: Clinician Signature:

Date: Time:



Client Name: MPI: B. Food Management:Basic- Must know 3 of 4 to advance to next level of accomplishment

Knows that it is important to wash hands before eating and preparing foodKnows how to describe food groups (such as the “My Plate” nutrition guide) and foods that contribute to a healthy lifestyleKnows how to order in a cafeteria or fast food restaurantKnows name and use of cooking utensils

Intermediate Must know 5 out of 6 to advance to next level of accomplishmentKnows how to order a meal from the menu in a restaurantKnows how to fix a breakfast, lunch, and dinner for oneKnows how to tell when food is properly and thoroughly cookedKnows how to make out a grocery shopping listKnows how to use cooking utensils effectively and safelyKnows how to use kitchen appliances effectively and safely

Advanced- Must know 6 of 8 to be rated as AdvancedKnows appropriate storage place for different food itemsKnows the signs of spoilage in food, and can use dates on food packages to prevent spoilageKnows how to follow the instructions for preparing canned or frozen foodsKnows how to plan a weekly menu of nutritious mealsKnows how to shop for a week’s menu and stay within food budgetKnows how to set the table properlyKnows how to carry out a grocery shopping trip on their ownKnows how to prepare a meal using a recipe and can adjust recipe for more/less people

Stage of Change




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Client Name: MPI: C. Personal Appearance & Hygiene:Basic- Must know 3 of 3 to advance to next level of accomplishment

Understands the importance of showering or bathing regularlyKnows how to use and cost of shampoo, soap, deodorant, shaving cream, other common personal products appropriate to gender identityKnows the importance of brushing teeth regularly

Intermediate- Must know 4 of 4 to advance to next level of accomplishmentKnows how to keep hair neat and clean (knows how to use basic grooming tools such as hair dryer, razor, brush, comb, etc.)Knows how to dress in clean clothing appropriate to the seasonKnows how to sort laundry into loads based on color & fabricKnows how to read clothing labels to determine which clothes are to be dry-cleaned, hand washed, and machine-washed

Advanced – Must know 5 of 6 to be rated as AdvancedKnows how to use appropriate stain removal techniques for different types of stainsKnows how to wash clothes using appropriate temperatures, amounts of soap, bleach etc.Knows how to dry clothes in dryer using appropriate settingsKnows the cost of and knows how to budget money for special hair/nail careKnows how to iron clothes if neededKnows appropriate clothing to wear for all occasions/events.

Stage of Change




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Client Name: MPI: D. Home Management:Basic- Must know 3 of 4 to be advanced to next level of accomplishment

Knows how to wash dishes adequately using soap and hot waterKnows how to change a light bulbKnows how to make a bedKnows how to dispose of garbage

Intermediate- Must know 5 of 6 to move to next level of accomplishmentKnows how to use vacuum cleaner properly and change bagsKnows how to change bed-linenKnows how to prevent sinks and toilets from cloggingKnows how to sweep floor and stairs, wash wood and linoleum floors, wash windows, dust, polish furniture, clean toilet/tub/sinkKnows appropriate cleaning products to use for different cleaning jobsKnows how to clean a stove

Advanced- Must know 5 of 6 to be rated as AdvancedKnows how to stop toilet from runningKnows how to use a plunger to unstop a toilet or sinkKnows how to perform routine house-cleaning to maintain the home in a reasonably clean state without assistanceKnows how to change a fuse or reset a circuit breakerKnows how to conserve energy and waterKnows how to get rid of and avoid roaches, ants, mice, etc.

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Client Name: MPI: E. Housing:Basic- Must know 2 of 2 to be rated advanced to the next level of accomplishment

Understands concept of rentingKnows how to access emergency shelter

Intermediate- Must know 3 of 4 to be advanced to next level of accomplishmentKnows how to look for housing using newspaper, realtor, internet, etc.Understands basic terms (lease, sub-let, utilities, studio, efficiency, security deposit, reference, etc.)Knows how to calculate the costs associated with different types of housing & identify type of housing that is within budget and meets current housing needs.Knows the pros/cons of having/choosing a roommate

Advanced- Must know 5 of 6 to be rated as AdvancedKnows how to calculate “start-up” costs (utility deposits, connection fees, security deposit, 1st month’s rent, purchase of furniture, etc.)Knows how to complete a rental applicationKnows to inspect the apartment to make sure appliances work and that the landlord has supplied accurate information about the apartment and neighborhoodKnows and understands the concept of a lease and landlord/tenant rights and responsibilitiesUnderstands the rights of other residents with regard to property and noise and understands the consequences if the rights of others are not respectedKnows the role of the landlord including what repairs they should perform on the apartment should they arise

Stage of Change




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Client Name: MPI: F. Transportation:Basic- Must know 3 of 3 to be able to advance to next level of accomplishment

Knows the different types of public transportation availableKnows the nearest public bus stop to your homeKnows amount of money required for bus fare

Intermediate- Must know 3 of 3 to be able to advance to next level of accomplishmentKnows how to call a taxi and provide information needed, Knows approximate cost of taking taxiKnows how to plan a trip using bus system including (times, where to get on, transfers, departure location, cost, etc.)Knows how to ask for directions when lost

Advanced- Must know 3 of 3 to be rated as AdvancedIf given instructions, knows how to make public transportation journey involving several transfersKnows how to access a map online and follow directions to a designated locationKnows what is required to get a driver’s license

Stage of Change




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Client Name: MPI: G. Emergency & Fire Safety Skills:Basic- Must know 4 of 5 to be able to advance to next level of accomplishment

Knows functions of police, ambulance, fire department and can reach by calling appropriate numberKnows to evacuate residence in case of fireUnderstands basic fire prevention (properly dispose of smoking material, using gas stove to heat house etc.)Knows how to check smoke alarm and how to replace batteryKnows how to lock/unlock doors/windows.

Intermediate- Must know 4 of 5 to move to the next level of accomplishmentKnows how to use a fire extinguisherKnows that improperly used appliances can cause fires or electrocution.Knows how to recognize the smell of a gas leak and knows what to do/whom to call if they smell a gas leakKnows at least three precautions for protecting oneself at home and in the communityUnderstands and can recognize common dangers in the community (i.e., crossing streets, unlit/poorly lit areas, victimization)

Advanced- Must know 3 of 3 to be rated as Advanced.Knows the different methods for putting out different types of firesKnows how to properly store cleaning materialsKnows how to determine when professional medical help is needed

Stage of Change




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Client Name: MPI: H. Health & Wellness:Basic- Must know 8 of 10 to be able to advance to next level of accomplishment

Knows personal and family health history (medical, dental, mental health)Understands the risks of drug (including nicotine) and alcohol abuseCan recognize and describe the symptoms of a cold, the flu and other common health problemsUnderstands how to maintain oral health care and when to seek out treatmentKnows major parts of the body and their basic function (heart, lungs, etc.)Knows contact information for how to access emergency services (EMS, Fire, health proxy, etc.)Knows how and where to get emergency health careKnows how to use a first aid kit (for a minor cut, minor burn, splinter, etc.)Knows own height and weight and implications related to bothCan select a doctor, dentist or clinic for regular healthcare

Intermediate- Must know 9 of 12 to move to the next level of accomplishmentKnows how to obtain a copy of personal immunization records and medical historyKnows own blood pressure and pulse rate and implications related to bothKnows how to use simple in-home medical items (thermometer, pregnancy test, etc.)Knows (if applicable) how to care for and maintain own medical equipment (inhaler, nebulizer, glucometer, EpiPen, asthma pump, etc.)Understands diagnoses, allergies and if medically complex – special care needs with associated prognosis and treatment.Knows how to nurse self through a cold or the flu and care for own minor injuriesKnows how to make and keep appointments with health care professionals (doctor, dentist, clinician, etc.)Understands labs and important tests as they relate to own special healthcare needsUnderstands confidentiality, HIPAA and consentsUnderstands the importance of sleep in relation to daily functioningUnderstands what medical insurance is and why it is importantCan determine when to go to an emergency room and when to make an appointment with the family doctor or walk-in clinic

Advanced- Must know 6 of 8 to be rated as Advanced.Understands patient rights and knows how to advocate for self on health care issues with medical professionals and behavioral health care providersCan identify at least one adult whom they trust who would be legally allowed to make medical decisions for me and advocate for me if I was unable to speak for myself as a health care proxy.Understands how diet and exercise impacts healthKnows healthy methods for reducing stress and anxietyCan explain to others their mental health, physical symptoms and treatment/services that they are receivingUnderstands the benefits from engaging in healthy leisure activitiesHas and knows how to obtain and/or maintain active enrollment in healthcare insurance (how to enroll, benefits, provider network)Knows how to access resources to assist with health and wellness concerns (primary medical care physician, walk-in clinic, mental health provider, etc.)

Stage of Change


Staff/Client Comments:(Include reason for



Client Name: MPI: deferral, if appropriate)


Date: Time:

I. Educational Planning:Basic- Must know 2 of 2 to be able to advance to next level of accomplishment

Has a realistic view of his/her educational goalsKnows what a GED is and how to obtain one (if applicable)

Intermediate- Must know 3 of 4 to move to the next level of accomplishmentKnows how to fill out forms to enroll in an educational programHas a general idea of what educational degree (diploma, GED, certificate, associates, bachelors, masters, etc.) is needed for the job he/she wantsKnows how to discuss educational/vocational plans with othersKnows of educational resources available in the community

Advanced- Must know 7 of 9 to be rated as Advanced.Knows how to obtain school transcriptsKnows current educational credits and standingKnows how to develop appropriate educational plan for the job selectedUnderstands the educational/skill requirements for the job selectedIs aware of the cost of higher education/vocational trainingKnows the difference between a loan and a grantKnows where to find and how to access adult education or vocational training in the communityKnows how to obtain financial aid/scholarships for educationUnderstands future prospects and probable living standards relative to levels of education and specialized skills

Stage of Change




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Client Name: MPI: J. Job Seeking Skills:Basic- Must know 2 of 2 to be able to advance to next level of accomplishment

Knows how to develop a realistic plan for vocational goalsKnows what the minimum wage is

Intermediate- Must know 6 of 8 to move to the next level of accomplishmentKnows how to read want ads and find appropriate leadsKnows how to fill out a standard (paper) job application formKnows how to complete a mock interview giving appropriate answers to potential questionsKnows how to make an appointment for a job interviewKnows appropriate clothing to wear for the interviewKnows how to write a resumeKnows how to prepare for a job interviewKnows how to participate in a job interview

Advanced- Must know 6 of 7 to be rated as Advanced.Knows the function of and can contact the public employment agencyKnows how to fill out an on-line job application formKnows the function of, and fees associated with, private employment agenciesKnows how to follow up an interview with a letterUnderstands and can weigh the advantages of one job over anotherUnderstands what discrimination is and where to seek help if discriminated againstKnows the purpose of and can contact a “Temp” Agency

Stage of Change




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Client Name: MPI: K. Job Maintenance Skills: (Complete this section ONLY if the client is employed)Basic- Must know 3 of 4 to be able to advance to next level of accomplishment

Knows how to dress for work appropriatelyKnows the importance of reporting to work on timeKnows job responsibilities and how to complete job tasksKnows to contact employer when not able to go to work.

Intermediate- Must know 4 of 5 to move to the next level of accomplishmentKnows appropriate way to talk to supervisorKnows what behaviors will get a person fired immediatelyKnows how to read a pay stubKnows how to ask for help with a problem on the jobKnows if eligible for sick time, vacation time, or personal time and if so, rate of accrual

Advanced- Must know 6 of 8 to be rated as Advanced.Knows how to handle anger in an appropriate manner when angry at supervisor, co-worker, or customersKnows where and when it is acceptable (and not acceptable) to chat with co-workersKnows how to use company grievance procedure to report and resolve disputes/issues/concernsKnows company’s “unwritten policies” and can adhere to themKnows what to do/how to ask for a raiseKnows what to do to be eligible for a promotionKnows legal rights as an employeeKnows and can describe what supports/assistance they may need to maintain employment

Stage of Change




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Client Name: MPI: L. Knowledge of Community Resources:Basic- Must know 5 of 6 to be able to advance to next level of accomplishment

Knows how to get emergency information by the telephoneKnows whom to contact if injured or sickKnows where the nearest supermarket or shopping district is locatedKnows how to access emergency food and shelterKnows how to access a crisis lineKnows location of the nearest hospital

Intermediate- Must know 6 of 8 to move to the next level of accomplishmentKnows where the nearest Laundromat is locatedKnows how to find leisure activities in the communityKnows how to find a self-help group or religious organization for supportKnows where personal bank (or nearest local bank) is locatedKnows how to obtain information by using Infoline, the internet, phonebook, etc.Knows the location of the nearest community health care providerKnows the location of the nearest post offices and how to use itKnows the location of the nearest library and how to use the resources there (i.e. library card, computer use, taking out books or movies, etc.)

Advanced- Must know 5 of 6 to be rated as Advanced.Knows whom to contact if utilities are disconnected or heat goes outKnows where the nearest state employment office is locatedKnows how to obtain a copy of his/her birth certificate or duplicate social security cardHas awareness of “specialized” resources: mental health counseling, Department of Social Services, credit counseling, Planned Parenthood, student aid offices, tenant groups, CLRP, animal control, public recreation, etc.Knows who elected representatives are and how to contact themKnows what the Better Business Bureau does and how/when to contact them

Stage of Change




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Client Name: MPI: M. Interpersonal Skills:Basic- Must know 4 of 5 to be able to advance to next level of accomplishment

Knows how to respond to introductions and answer simple questionsKnows at least one friendKnows how to look others in the eye and shakes hands if other person offersKnows how to make “small talk” face to faceKnows the importance of communicating with at least one person weekly

Intermediate- Must know 6 of 7 to move to the next level of accomplishmentKnows how to make introductions, including approaching others to introduce selfKnows what “boundaries” areKnows the implications of sharing personal information through the use of technology (internet, texting, social media, etc.)Knows how to treat others properlyKnows how and when to ask for helpKnows how to explain and express feelings/opinionsKnows how to identify relationships that may be hurtful or dangerous

Advanced- Must know 8 of 10 to be rated as Advanced.Knows how to identify personal strengths and needs (with assistance if necessary)Knows how to accept invitations from others to be involved in social activitiesKnows how to make arrangements with peers for social activitiesKnows where to get help if unable to resolve interpersonal conflicts aloneKnows how to resolve conflicts with othersKnows how to refrain from using physical violence as a means of solving interpersonal conflictKnows how to say “no” to a peer who is trying to pressure him/herKnows how to develop a realistic plan to deal with peer pressure along with appropriate steps identified to carry out the planKnow what “good” table manners are (can use a knife and fork, napkins appropriately, knows proper etiquette in restaurants, etc.)Knows how to avoid hurtful or dangerous relationships

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Client Name: MPI: N. Legal Skills: (As applicable if involved in the legal system)Basic- Must know 2 of 2 to be able to advance to next level of accomplishment

Knows the phone number of someone to call if arrested or victimizedUnderstands generally what actions are against the law and what the consequences are

Intermediate- Must know 6 of 7 to move to the next level of accomplishmentKnows personal rights if arrestedKnows what the function of a lawyer isKnows the legal age for buying alcohol and tobacco productsUnderstands the meaning of “legal age” (what you can and can’t do)Knows how to read a contractKnows how and where to register to voteKnows the responsibilities of a conservator or representative payee (if applicable)

Advanced- Must know 4 of 5 to be rated as Advanced.Knows the responsibility to register for selective service (if male)Understands his/her rights to make choices about his/her medical care through an Advance DirectiveKnows of how and where to access free legal servicesUnderstands the consequences of signing a contract or leaseKnows the legal penalty for all of the following:

Buying, selling, possessing and smoking marijuana and other drugs Buying and drinking alcohol if under age Trespassing Shoplifting Burglary Possession of stolen property Traffic violations

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Client Name: MPI: O. Coping Skills:Basic- Must know 4 of 5 to advance to the next level of accomplishment

Knows what “stress” is, can explain/define it.Knows what a “trigger” isKnows what a “crisis plan” is (i.e. WRAP)Knows what to do if symptoms become unmanageableKnow what it means to feel good about oneself (self-esteem)

Intermediate- Must know 9 of 12 to advance to the next level of accomplishmentKnows how to identify stressors (personal to them)Knows how their body feels/responds when stressed, anxious, etc.Knows how to recognize signs/symptoms of stressKnows how to identify and give name to various emotions that they experience (stress, anxiety, anger, sadness happiness)Knows how to identify at least 3 coping strategies (may not yet be able to apply them, but can identify them)Knows how to identify their own “triggers” that may lead to relapseKnows how to identify at least three or more supports (at least one of which must be outside of the mental health system such as a relative, friend, pastor, etc.)Knows how to distinguish between a true emergency/crisis and minor problem/issueKnows how to develop a “crisis” planKnow how to identify ways to reduce or prevent stress/anxietyKnows the importance of hobbies and leisure timeKnows how to describe how they feel when they are feeling well

Advanced- Must know 6 of 8 to be rated as advancedKnows how to manage emotions properly (does not “fly off the handle” in rage or sob inconsolably in response to minor issues)Knows how to assert oneself and advocate for oneself appropriately (without being too aggressive or too passive)Knows how to talk about their feelings openly (with significant others, with natural supports, with therapist, etc)Knows how to ask for advice or support from someoneKnows how to cope with difficult situations and emotionsKnows how to identify barriers that may get in the way of being able to copeKnows how to identify appropriate coping skills and strategiesKnows how to use their “crisis” plan

Stage of Change




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Client Name: MPI: P. Anger Management: (As applicable)Basic- Must know 5 of 6 to advance to the next level of accomplishment

Knows how anger escalatesKnows how to identify physiological symptoms associated with angerKnows how to identify triggers of angerKnows how to identify thoughts and feelings associated with angerKnows how to identify activities/strategies to manage physiological signs/symptoms of angerKnows how to identify support network for dealing with difficult situations

Intermediate- Must know 4 of 5 to advance to the next level of accomplishmentUnderstands the different types of behavior (passive, passive-aggressive, aggressive and assertive)Knows how to identify own personal style of conflict resolutionUnderstands the impact of body language on conflict resolutionUnderstands the effects of anger on different aspects of lifeUnderstands how substances influence anger

Advanced- Must know 4 of 5 to be rated as advancedKnows how to identify alternative responses/outcomes to manage triggers (other than anger)Knows how to be assertive in conversations by using “I statements”Understands what the effect of self-talk (negative vs. positive) has on angerKnows how to identify verbal and non-verbal ways to deal with conflictKnows appropriate verbal and non-verbal ways to respond to conflict

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Client Name: MPI: Q. Relationships:Basic- Must know 3 of 4 to advance to the next level of accomplishment

Knows how to identify supportive people and organizations from which to seek help for relationship issuesKnows how to identify what qualities to look for in a partner and ones to avoidKnows how to identify what physical abuse isKnows how to explain what love is

Intermediate- Must know 4 of 5 to advance to the next level of accomplishmentKnows how to identify how relationships have an impact (positive or negative) on their lifeKnows the signs and symptoms of an abusive relationshipKnows how to identify three forms of abuse (physical, sexual, emotional)Knows how to identify healthy roles and behaviors in a relationshipKnows how to identify appropriate ways to start a relationship

Advanced- Must know 5 of 6 to be rated as advancedKnows how to establish relationship valuesUnderstands the effects of domestic violenceKnows what domestic violence is and it’s causesKnows ways to protect oneself if in an abusive relationshipUnderstands the pros and cons to having a sexual relationshipKnows when a relationship has come to an end and can manage appropriately

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Client Name: MPI: R. Pregnancy Prevention:Basic- Must know 3 of 3 to be able to advance to next level of accomplishment

Knows how pregnancy occursKnows methods of birth control and how to obtain birth controlKnows where to go to get information on sex or pregnancy

Intermediate- Must know 3 of 4 to move to the next level of accomplishmentKnows how to properly use birth controlUnderstands the risks of unprotected sex and sexually transmitted diseases/infectionsKnows locations of family planning officeKnows options for birth control (male and female)

Advanced- Must know 3 of 3 to be rated as Advanced.Knows options for pregnancy (carry to term, adoption, termination)Knows how to prevent the spread of sexually transmitted diseases/infectionsKnows where to go for treatment for sexually transmitted diseases/infections

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Client Name: MPI: S. Parenting & Childcare: (As applicable)Basic- Must know 3 of 4 to be able to advance to next level of accomplishment

Knows the signs and symptoms of pregnancyUnderstands the biology of pregnancy and childbirthKnows dangers of drugs, alcohol and tobacco during pregnancyKnows what adequate pre-natal care is

Intermediate- Must know 8 of 10 to move to the next level of accomplishmentKnows where to obtain pre-natal careKnows not to leave child without supervision and can provide appropriate supervision for a childKnows how to care for a child when aloneKnows the proper position to place a newborn baby to sleepKnows how to properly use a car seat for transporting small child(ren)Knows how to bathe a child and change diapersKnows how to engage child in appropriate play (reading, singing, drawing, building, etc.)Knows the available options for regular childcareKnows how to select appropriate people to periodically baby-sit with childKnows where to go for help if child is sick

Advanced- Must know 9 of 12 to be rated as Advanced.Knows what toys and activities are appropriate for the child’s age and developmental levelKnows how to access community resources for children (Early Intervention, DCF, Women, Infants and Children, etc.)Knows how to discipline child without using extreme measures (hitting, screaming, withholding food or care)Knows how to make arrangements for regular childcare that is safe and age appropriateKnows the importance of taking their child to childcare on time, picking child up from childcare on timeKnows how to spend “quality” time with child each day (reading, talking, playing, listening to child, etc.)Knows where to go for help with parenting if neededKnows how to properly feed a child with age appropriate and nutritious foodsKnows how to choose a pediatrician and knows the importance of regular well-baby visitsKnows how to recognize age appropriate developmental milestonesKnows how to recognize and appropriately respond to their child’s needsKnows how and when to administer medications (prescription and over the counter) to child

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Client Name: MPI: T. Medication Management:Basic- Must know 6 of 7 to be able to advance to next level of accomplishment

Knows how to open a childproof containerKnows not to take someone else’s medicationKnows the names of the medications they are taking (or has a list of them to refer to)Knows the difference between prescription and over the counter medicationsKnows the diagnoses/reasons for which they are taking medications/supplementsKnows if they are allergic or have adverse reactions to medications/supplements and which onesKnows what their medications look like (appearance such as size, shape, color)

Intermediate- Must know 8 of 10 to move to the next level of accomplishmentKnows the dosages and how often to take their prescribed medicationsKnows and recognizes the potential side effects of their medicationsKnows what to do in the event of an overdoseKnows how to fill a weekly pill organizer with supervisionRecognizes/makes correct use of over the counter drugs for pain, stomach upset, diarrhea, fever, cold, allergy, etc.Knows how to read a prescription label correctly and follow the instructionsKnows how to call in refills and pick up medications at the pharmacy independently (if age 18 or over)Knows how to utilize all equipment/supplies related to medications with supervisionKnows how to obtain over the counter meds and the need to discuss all meds, vitamins and supplements with prescribing physician(s)Knows how to dispose of discontinued or expired medication safely

Advanced- Must know 7 of 9 to be rated as Advanced.Knows how to take medication without supervisionKnows what to do if experiencing side effects from the medicationsKnows how to prepare/manage medications in a safe mannerKnows how to independently schedule and maintain appointments with medication prescribersKnows how to ask necessary and appropriate questions of doctor or pharmacist regarding medicationsKnows how to adhere to lifestyle modifications as required by prescription medicationsKnows how to utilize and properly maintain all equipment/supplies related to medications independentlyUnderstands safe medication storage practicesUnderstands the therapeutic consequences of medication non-compliance

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