| Service Requestion Number | Number of individuals to be served | General description (age, guardian, natural supports, medical & mental health diagnosis, service Location) | Scope of Supports and implementation timeline | Notes (special staffing needs, etc.) | Service Delivery Schedule - Sunday | Service Delivery Schedule - Monday | Service Delivery Schedule - Tuesday | Service Delivery Schedule - Wednesday | Service Delivery Schedule - Thursday | Service Delivery Schedule - Friday | Service Delivery Schedule - Saturday | Funding Type and Allocation (HPC, ATR, etc.) | Amount of Unsupervised Time/Overnight Supervision Needs |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 259 | 1 | 16-year-old male with Fragile X and Autism. He is living at home with his mother in Xenia. | This individual needs assistance getting ready before school (showering, breakfast, etc.) and transportation to school. School is located in Bellbrook not far from their home. Individual needs picked up from school at 1:45pm and staff assistance until approx. 4:00pm with preparing a snack and doing something engaging. This would be Monday, Thursday, and Friday. On Tuesdays and Wednesdays, staff would work with him in the home and assist with daily living skills (getting ready, meals, etc.) and engagement. | Preferably male. | N/A | 6:15/6:30am-8:00am And 1:45pm-4:00pm | 8:00am-4:00pm | 8:00am-4:00pm | 6:15/6:30am-8:00am And 1:45pm-4:00pm | 6:15/6:30am-8:00am And 1:45pm-4:00pm | N/A | IO Waiver | None |
| Service Requestion Number | Number of individuals to be served | General description (age, guardian, natural supports, medical & mental health diagnosis, service Location) | Scope of Supports and implementation timeline | Notes (special staffing needs, etc.) | Service Delivery Schedule - Sunday | Service Delivery Schedule - Monday | Service Delivery Schedule - Tuesday | Service Delivery Schedule - Wednesday | Service Delivery Schedule - Thursday | Service Delivery Schedule - Friday | Service Delivery Schedule - Saturday | Funding Type and Allocation (HPC, ATR, etc.) | Amount of Unsupervised Time/Overnight Supervision Needs |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 259 | 1 | 16-year-old male with Fragile X and Autism. He is living at home with his mother in Xenia. | This individual needs assistance getting ready before school (showering, breakfast, etc.) and transportation to school. School is located in Bellbrook not far from their home. Individual needs picked up from school at 1:45pm and staff assistance until approx. 4:00pm with preparing a snack and doing something engaging. This would be Monday, Thursday, and Friday. On Tuesdays and Wednesdays, staff would work with him in the home and assist with daily living skills (getting ready, meals, etc.) and engagement. | Preferably male. | N/A | 6:15/6:30am-8:00am And 1:45pm-4:00pm | 8:00am-4:00pm | 8:00am-4:00pm | 6:15/6:30am-8:00am And 1:45pm-4:00pm | 6:15/6:30am-8:00am And 1:45pm-4:00pm | N/A | IO Waiver | None |