Personal Information Sheet
 Name __________________________________________Grad. Date 
 _________________
 Address 
 _____________________________________________________________________
                              F      M
 City, State, Zip code 
 ________________________________________________________
 Birthdate ________________________________ Age ___________  Sex 
 Parents/Guardian Name ________________________________________________
 _____________
 Is student conserved      yes       no
 Phone Number ____________________________ SS # _________ _______ _________
 Address if different than above 
 High School Attended ___________________________ Yr. Graduated _________
 _________________________________________
 ____________________________________________________________________________
 _
 Medical Information:
 Phone/Cell Number _____________________________________________________
 Mark all that apply
 Glasses       
                 Allergies ___________________________
 Seizures      
                 Illnesses ___________________________
 Medications – List 
  ______________________________________________________
 Primary Diagnosis 
 _________________________________________________________
 Secondary Diagnosis 
 ______________________________________________________
   Parent/Guardian Assessment
 1. What chores or responsibilities does  your student have at home?  
 ______________________________________________________________________________
 _
 ______________________________________________________________________________
 _
 2. What tasks would you like your student to be able to do at home?
 ______________________________________________________________________________
 _
 ______________________________________________________________________________
 _
                                  Group home
                                  
 3. After graduation from ABLE, what do you think your students 
                                     Other _____________________
 living situation will be?
 At home
 Apartment with support
                                Social skills
                                Sex education
 4. In which of the following areas of independence do you think your 
 student needs help in:         Organizational skills
                                Household management
 Clothing care                 Self-advocacy
 Consumer Case                 Health/First aid
 Meal preparation              Recreation/Leisure
 Nutrition                     Other _____________________
 Community awareness
 Hygiene
 Transportation
 Safety
 5. What leisure or recreational activities does your student do 
 alone? 
 _______________________________________________________________________
 ______________________________________________________________________________
 _
 6. What leisure/recreational activities does your student do with 
 family? 
 ______________________________________________________________________
 ______________________________________________________________________________
 _
 7. What leisure/recreational activities does your student participate 
 in with friends? 
 ____________________________________________________________
 ______________________________________________________________________________
 _
 8. What leisure/recreational activities would you like to see your 
 student participate in? 
 ____________________________________________________
 ______________________________________________________________________________
 _
 9. Does your student transition well from one thing to another? _____  
 Have there been any problems? 
 __________________________________________
 ______________________________________________________________________________
 _
 10.What agencies currently provide service for your student?________
 ______________________________________________________________________________
 _
                    Supported employment
 11. What would you like the school to do to assist you with the 
                    Day program
 planning of your students living, working and educational needs 
                    Home
 prior to graduation? 
 _______________________________________________________
 ______________________________________________________________________________
 _
 ______________________________________________________________________________
 _
 12. Where do you see your student after graduating?
 Further education
 Full time employment
 Part time employment
             Personal Assessment
 1. What chores or responsibilities do you have at home?  
 ______________________________________________________________________________
 _
 ______________________________________________________________________________
 _
 2. What tasks would you like to be able to do at home?
 ______________________________________________________________________________
 _
 ______________________________________________________________________________
 _                                 Group home
                                   Other _____________________
 3. After graduation, what do you think your living situation will be?
 At home
 Independent Living
                                 Social skills
                                 Sex education
 4. In which of the following areas of independence do you think you 
 need help in:                   Organizational skills
                                 Household management
 Clothing care                  Self-advocacy
 Consumer Case                  Health/First aid
 Meal preparation               Recreation/Leisure
 Nutrition                      Other _____________________
 Community awareness
 Hygiene
 Transportation
 Safety
 5. What leisure or recreational activities do you do when you’re 
 alone? 
 _______________________________________________________________________
 ______________________________________________________________________________
 _
 6. What leisure/recreational activities do you do with your family? 
 ______________________________________________________________________________
 _
 ______________________________________________________________________________
 _
 7. What leisure/recreational activities do you participate in with 
 your friends? 
 _______________________________________________________________
 ______________________________________________________________________________
 _
 8. What leisure/recreational activities would you like to see yourself 
  participating in? 
 ___________________________________________________________
 ______________________________________________________________________________
 _
 9. Do you transition well from one activity to another? _______  Have 
 there been any problems? ________________________________________________
 ______________________________________________________________________________
 _
 10.What agencies currently provide service to you?___________________
 ______________________________________________________________________________
 _
                    Supported employment
 11. What would you like the school to do to assist you with your 
                    Day program
 living, working and educational needs prior to graduating? 
                    Home
 ______________________________________________________________________________
 _
 ______________________________________________________________________________
 _
 ______________________________________________________________________________
 _
 12. Where do you see yourself after graduating?
 Further education
 Full time employment
 Part time employment