CHW Packet – Community Connections Daily NoteCHW Packet - Community Connections Daily NoteFamily Connections, LLC 1643 Warwick Avenue, #200, Warwick RI 02889 Phone: 401-952-8188 Fax: 401-385-9410 familyconnections@familyconnectionsri.com familyconnectionsri.com Please enable JavaScript in your browser to complete this form.LayoutClient Name *FirstLastDate of ServiceTime InTime OutLocation Of Service:12 Home04 Homeless Shelter11 Office53 Health CenterHome: Having a stable and safe place to live Health: Overcoming or managing one's disease(s) or symptoms, and making informed, healthy choices that support physical and emotional well being Purpose: conducting meaningful daily activities, such as a job, school, volunteerism, family caretaking or creative endeavors and the independence, income and resources to participate in society Community: Having relationships and social networks that provide support, friendship, love and hopeICD 10: HomeZ59.1 Inadequate HousingZ59.9 Problems related to housing economic Circumstances UnspecificICD 10: HealthPurpose:Z59.6 Low IncomeZ55.9 Problems related to educationOtherOther:Community:Z63.0 Problems in relationshipZ63.5 Disruption of family Separation and DivorceZ63.8 Other Problem related to Primary Support GroupZ65.3 Problems related to other Legal CircumstancesOtherOtherCHW Plan of care: Progress notes based on ICD 101. Home:1. Plan for next session2. Health:2. Plan for next session3. Community - Relationships:3. Plan for next session4. Purpose:4. Plan for next sessionNotes that need coordination with Primary Clinician:LayoutSignature of CHW: Clear Signature *The signing of this note declares this information to be accurate and a true representation of services providedDateLayout (copy)Print FC Staff Name:FC Email:Submit