Support Worker name* Support Worker mobile number Full Name of Service User* First name Surname Local Authority* Bridgend Carmarthenshire Neath Port Talbot Swansea Other Date of contact: Contact start time: Contact finish time: Persons mood at the start of the session*Please tick the relevant box Is there a planned activity? Yes No What activity did you and the person agree to do? About the activityPlease describe the activity, how long you stayed there for, did the person enjoy it?Other activities completed during the sessionPlease describe the activity, how long you stayed there for, did the person enjoy it?What did the person eat during this session?Did the person eat all their food? Yes No Did the person ask for more food after eating what they had? Yes No What were the high points during the session?Describe any positive communication, interaction, gestures and actions.What were the low points during the session?Describe any difficult moments, poor communication, aggressive gestures and negative actions.What were the learning points for the person during the session?What did the person learn during this session about communication, life skills, basic skills, interaction with others and support staff?What were the learning points for support staff during the session?What did the support worker learn during this session about the person or about how they managed the support session?Persons mood at the end of the session:*Please tick the relevant box Were there any comments are views from the person that need to be noted and shared with management and/or family?Were there any comments are views from the persons family/guardian that need to be noted and shared with management and/or social worker?Any other feedback?ABC Behaviour ChartWhere did behaviour happen? AntecedentsWhat was the persons mood immediately before the behavioural response?Please tick the relevant box What happened immediately before the behavioural response?Please Include any triggers, signs of distress or environmental information.BehaviourPlease describe how the behaviour presented i.e., what the behaviour 'looked' like?ConsequencesWhat was the persons mood immediately after the behavioural response?Please tick the relevant box What were the consequences of the behaviour, or what happened immediately after the behaviour?Please include information about other people's responses to the behaviour and the eventual outcome for those involved.2-2-1 Service Yes No Name of both staff Who was Driving? Any Other Comments / NotesComments / NotesPlease provide any further information you feel is relevant here e.g. your interpretation of what may be the trigger/s and what strategies may be helpful to manage this in future.Your name* Privacy* By using this form you agree with the storage and handling of your data by this website. More information >> PhoneThis field is for validation purposes and should be left unchanged.
