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Client phone number
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Start date
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End date
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Follow up call desired?
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Service area
• • •
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Client goals
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Client objectives
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Client objectives
• • •
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Was objective met?
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Other objective(s)
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Was objective met?
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If no, please list what wasn't met
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Increased independence goal met
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Adjustment to vision loss met
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Total direct time spent working on goals
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Total indirect time spent
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Progress note
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Signature:
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Signed by
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Signature:
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Signed by
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Supervision statement
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