FIRST NAME:
Alec
LAST NAME:
Davis
DOB:
1988-03-12
GENDER:
Male
SSN:
60814q008
MEDICAID #:
ADDRESS:
5961 Attentee Rd
GROUP HOME NAME:
GROUP HOME ADDRESS:
PARENT/GUARDIAN NAME:
Kathryn Davis
PARENT/GUARDIAN PHONE:
202-765-8818
GUARDIAN EMAIL:
DAY PROGRAM NAME:
WREMLEX
DAY PROGRAM PHONE:
571-265-7202
REASON FOR REFERRAL
Voyage Inc could not provide on site BSP monitoring or training. Virtual was not working
DIAGNOSIS
GRIN2B NEURODEVELOPMENTAL, MILD GLOBAL CP
MEDICATIONS
See group home MARS for current list. If unavailable, please notify and I will send Pharmacy Alternative list
BEHAVIORS
Emotional Outburst
Frequency: Weekly
Severity: Moderate
Description: Will yell and cuss
Verbal Aggression
Frequency: Daily
Severity: Moderate
Description: Name calling, saying "I quit"
Self Injury
Frequency: Weekly
Severity: Moderate
Description: Will pick his cuticles until they bleed
Property Damage
Frequency: Monthly
Severity: Moderate
Description: Will rip his paper aduly breifs off because he hates them, will throw his glass and or cell phone
GUARDIAN CONSENT SIGNATURE
SUPPORT WORKER NAME
SUPPORT WORKER SIGNATURE
SIGNED DATE