NORTH CAROLINA DIVISION OF MENTAL HEALTH/DEVELOPMENTAL DISABILITIES/SUBSTANCE ABUSE SERVICES
DECEMBER 2025
CONSUMER NAME: ELIJAH WRIGHT - RECORD #: 816719_Medicaid ID#: 9512575698 from 02/11/25 TO 02/10/26 MONTH/YEAR-
SPECIFY SERVICE: 1915i T2012 GC-U4 CLS AREA PROGRAM/LME: Alliance Health SERVICE PROVIDER/AGENCY: NC Life of Rehabilitation Services, Inc.
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1- Elijah will participate in an integrated social activity of his choice in the community given 4 or less verbal prompts for 6 consecutive months.1/# A
2. Elijah 3 times per week will make his own choice of activities in the community site given 4 or less Verbal Prompt for 6 consecutive months.1# A
3- Elijah staff will help him to increase his ability to choose the right activity in the community to help him increase his social activity given 3 or less verbal prompts for 6 months.1# A
4- Elijah will increase his ability to identify and implement positive coping skills to assist with managing his behaviors given 3 or less verbal prompts for 6 Consecutive months1/# A
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A
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A
DURATION (WHEN REQUIRED)
DATE
INITIALS
NORTH CAROLINA DIVISION OF MENTAL HEALTH/DEVELOPMENTAL DISABILITIES/SUBSTANCE ABUSE SERVICES
DECEMBER 2025
CONSUMER NAME: ELIJAH WRIGHT - RECORD #: 816719_Medicaid ID#: 9512575698 from 02/11/25 TO 02/10/26 MONTH/YEAR-
SPECIFY SERVICE: 1915i T2012 GC-U4 CLS AREA PROGRAM/LME: Alliance Health SERVICE PROVIDER/AGENCY: NC Life of Rehabilitation Services, Inc.
DATE
COMMENTS
No behavioral events recorded for this period.
ALL STAFF PERSONS WORKING WITH THIS INDIVIDUAL MUST FILL OUT THE INFORMATION BELOW
STAFF NAME (PLEASE PRINT)STAFF SIGNATURE, TITLEINITIALS
DSP
Key: (VP=Verbal prompt) (PP Physical Prompt) (M=Meet) (U=Not Meet) (I=Independent) (NA=Not Apply) (TL Therapeutic Leave) (R=Refuse)
Note: All goals will be measured at 100%
Qualified Professional Signature(QP):
Date: