Self-Management Assessment Form

Area of Need

Is this person able to independently self-manage in this area?

Yes

No

N/A

Describe their overall strengths, functional skills, and abilities

Area of Need

Is this person able to independently self-manage in this area?

Yes

No

N/A

Describe their overall strengths, functional skills, and abilities

Area of Need

Is this person able to independently self-manage in this area?

Yes

No

N/A

Describe their overall strengths, functional skills, and abilities

Area of Need

Is this person able to independently self-manage in this area?

Yes

No

N/A

Describe their overall strengths, functional skills, and abilities

Area of Need

Is this person able to independently self-manage in this area?

Yes

No

N/A

Describe their overall strengths, functional skills, and abilities

Area of Need

Is this person able to independently self-manage in this area?

Yes

No

Describe their overall strengths, functional skills, and abilities

Area of Need

Is this person able to independently self-manage in this area?

Yes

No

N/A

Describe their overall strengths, functional skills, and abilities

Supports and Outcomes for Health and Medical:

Does this person need or want supports in this area?

Yes

No

List in CSSP Addendum

Does this person need or want to set an outcome related to acquiring, retaining, or improving sills in this area?

Yes

No

List in CSSP Addendum

Area of Need

Is this person able to independently self-manage in this area?

Yes

No

N/A

Describe their overall strengths, functional skills, and abilities

Area of Need

Is this person able to independently self-manage in this area?

Yes

No

Describe their overall strengths, functional skills, and abilities

Area of Need

Is this person able to independently self-manage in this area?

Yes

No

Describe their overall strengths, functional skills, and abilities

Area of Need

Is this person able to independently self-manage in this area?

Yes

No

Describe their overall strengths, functional skills, and abilities

Area of Need

Is this person able to independently self-manage in this area?

Yes

No

Describe their overall strengths, functional skills, and abilities

Area of Need

Is this person able to independently self-manage in this area?

Yes

No

N/A

Describe their overall strengths, functional skills, and abilities

Supports and Outcomes for Personal Safety:

Does this person need or want supports in this area?

Yes

No

List in CSSP Addendum

Does this person need or want to set an outcome related to acquiring, retaining, or improving sills in this area?

Yes

No

List in CSSP Addendum

Area of Need

Is this person able to independently self-manage in this area?

Yes

No

Describe their overall strengths, functional skills, and abilities

Area of Need

Is this person able to independently self-manage in this area?

Yes

No

Describe their overall strengths, functional skills, and abilities

Area of Need

Is this person able to independently self-manage in this area?

Yes

No

Describe their overall strengths, functional skills, and abilities

Area of Need

Is this person able to independently self-manage in this area?

Yes

No

Describe their overall strengths, functional skills, and abilities

Supports and Outcomes for Activities of Daily Living:

Does this person need or want supports in this area?

Yes

No

List in CSSP Addendum

Does this person need or want to set an outcome related to acquiring, retaining, or improving sills in this area?

Yes

No

List in CSSP Addendum

Area of Need

Is this person able to independently self-manage in this area?

Yes

No

Describe their overall strengths, functional skills, and abilities

Area of Need

Is this person able to independently self-manage in this area?

Yes

No

Describe their overall strengths, functional skills, and abilities

Area of Need

Is this person able to independently self-manage in this area?

Yes

No

Describe their overall strengths, functional skills, and abilities

Area of Need

Is this person able to independently self-manage in this area?

Yes

No

Describe their overall strengths, functional skills, and abilities

Area of Need

Is this person able to independently self-manage in this area?

Yes

No

Describe their overall strengths, functional skills, and abilities

Supports and Outcomes for Instrumental Activities of Daily Living:

Does this person need or want supports in this area?

Yes

No

List in CSSP Addendum

Does this person need or want to set an outcome related to acquiring, retaining, or improving sills in this area?

Yes

No

List in CSSP Addendum

Area of Need
(Mental Health Crisis that requires the program to call 911 or an intervention team)

Is this person able to independently self-manage in this area?

Yes

No

N/A

Describe their overall strengths, functional skills, and abilities

Area of Need
(An act or situation that requires the program to call 911, law enforcement, or the fire department)

Is this person able to independently self-manage in this area?

Yes

No

N/A

Describe their overall strengths, functional skills, and abilities

Area of Need

Is this person able to independently self-manage in this area?

Yes

No

N/A

Describe their overall strengths, functional skills, and abilities

Area of Need
Conduct against another person receiving services that:

It substantially interferes with a person’s opportunity to participate or receive services/supports
Places the person in actual and reasonable fear of harm
Place the person in actual and reasonable fear of damage to property
Substantially disrupts the orderly operation of the program

Is this person able to independently self-manage in this area?

Yes

No

N/A

Describe their overall strengths, functional skills, and abilities

Area of Need

Is this person able to independently self-manage in this area?

Yes

No

N/A

Describe their overall strengths, functional skills, and abilities

Supports and Outcomes for Symptoms or Behaviors:

Does this person need or want supports in this area?

Yes

No

List in CSSP Addendum

Does this person need or want to set an outcome related to acquiring, retaining, or improving sills in this area?

Yes

No

List in CSSP Addendum

All team members in attendance will sign, identify their title or role, and indicate the date they attended. Signature below also indicates approval.

Signature

Title/Role

Date

Signature

Title/Role

Date

Signature

Title/Role

Date

Signature

Title/Role

Date

Signature

Title/Role

Date

Signature

Title/Role

Date

Signature

Title/Role

Date

Signature

Title/Role

Date

Signature

Title/Role

Date

Per MN Statutes, section 245D.071, A Helping Hand Senior Care Services LLC. must distribute the Self-Management Assessment for signatures by the person and/or legal representative and case manager within 20 working days of the 45-day planning meeting [or within 10 working days of a service plan review meeting].

Date which the Self-Management Assessment was mailed to the person and/or legal representative, and the case manager:

Per MN Statutes, section 245D.071, A Helping Hand Senior Care Services LLC. may consider the Self-Management Assessment deemed approved and in effect if within 10 working days of the distribution, the person and/or legal representative or case manager has not signed and returned the Self-Management or has not proposed written modification. The Self-Management Assessment will remain in effect until the next annual or until the person and/or legal representative or case manager submits a written request to revise.