,> 1 mature of Saniterlan: Wicomi 0 County Health Date. 2 2 2 2 ME Maryland MENTOR Network ESCAPE PLAN ?ent to understand. Post to evacuate in less In the grid below, draw a sketc the layout of your home and mark the escape route. Make it simple and easy for the a copy in the Client?s Review within 48 hours whenever a Client is placed in your home, and assess the Client?s ab than 2.5 minutes. rills are required quarterly. - Please ors (D). lnclu and label each room and floor. Label all Exits (E) both windows and doors, ?re extinguishers (F), and smoke det airs, and the meeting place outside of the home. You may use re than one f0 A: Esir' ?'an (9l05) HWWC H?ol [TA/team: i MENTOR Maryland i The MENTOR Network ESCAPE PLAN 5 aw) Warm lient to understand. Post ke it simple and easy for the bility to evacuate in less mark the escape route. Ma me, and assess the Client?s a of the layout of your home an a Client is placed in your ho iew within 48 hours whenever uired quarterly. In the grid below, draw a sketch a copy in the Client's room. Rev? than 2.5 minutes. Fire Drills are req both windows and doors, lire ex more than one form. tinguishers (F), and smoke detectors (D). Label all Exits nd label each room and ?oor. tome. Yo Please draw a meeting place outside of the I include stairs, and th Esr "lan (9/05) DI A TER - MENTOR BEHAVIOR CHALLENGES CHECKLIST Mentor NameC?M gal [Exp 5' i "r . Date 9? Please indicate by using an X, after thoughtful consideration. your level of acceptance of the following behavior challenges. This information is used to help us in selecting the person most suited to your family and home. There are no right or wrong answers. Please mark each item. In addition. please put a check mark by each item you have experienced in dealing with persons with special needs. Temper tantrums Fighting Hitting/kicking Biting I k/ I self abusivelhead banging) Hair pulling Pinching self Destructive to own things Destructive to others' things Destructive to animals Stealing - at home Reeling in the neighborhood ?iHyperactive, mild Hyperactivity requiring medication (Sitealing - at school/day program Short attention span Nervous ?dgeting . . Lying occasionally Lying frequently Using profane language 1/ Talking back i/ l? Argumenrativeness (sassy) Bossiness Whining occasionally 1 Whining frequently 1/ Crying occasionally Crying frequently Egging - at home Begging - at school Vi Begging in the neighborhood Withdrawn Fearful Aloof - don't care attitude Needs own privacy Forgetful Self-con?dent Independent Ungrateful l/ Rejects love 1/ Disobedient Jealous Sel?sh Stubborn 1/ Depressed Moody Has poor self-image Dependent/clinging Lr/ insecure Manipulating to get own way Manipulating to divide parents 1/ Has explosive outbursts Excessive shyness 1/ Page 2 of 5 Rude interrupts Loud and noisy Refuses to share Picks Nose Seductive Exhibitionist Sexuaily aggressive behavior Has had eariv sexuai experimentation -same sex opposite sex Sexual inveivement - same sex Sexuai invoivement - apposite sex Engages in masturbation privateiy in front of others Effeminate maie Tomboy femaie Victim of sexuai abuse Hes peer relationships with peers Disrespectfui to teachers Under-achiever Daydreamer, doesn?t iisten. Fails to do hemeweridcheres Disruptive in program talks tee much can't sit still Aggressive to others Truant er ditches scheeUdav program Gifted Page 3 of 5 . . . ills iced Messy - sp nsils Sel?sh grabs :55; Eats between meais Eats to point of gagging Thumb-sucking i .- Sleepwaiking Eed wetting i Etcci smearing Facts occasionally frequentiy Fias personal hygiene frequently rPiays with matches from curiosity destructive i i i i (Runs away i i i Smokes cigarettes Smokes man'iuana Has dif?cuity accepting limits Has been exposed {c excessive vicience Have frequent contact with teachen?day i 1 program SUpEWiSDfl'ij coach Take person to therapy as scheduted Participate in therapy as required by i/ therapist Continue giving the person medication as tong as physician indicates the need i Complete required Paperwork . 1 -- 1 Accept Z. A I I I. --L arentts) who are schizophrenic Parentis] who are mentally retarded Parentisi who were in a mentai institution Parentis) who abused drugs . i w? w? ere in prison a: Stutters Talks with a lisg. dit?cutt to understand i Requires speech therapy i Witt always have trouble speaking and being understood Ii . 2-55-3514: Si i Sight in one only Sight is limited. Surgery may help or correct Person is permanently biind Mr? i I ever if 2:36? Signature of Mentor Date Signet re of Spouse Date {Re-v. Page 5 of 5 MENTOR of MARYLAND SELF AWARENESS QUESTIONNAIRE TO BE FILLED OUT INDIVIDUALLY BY EACH MENTOR OR COUPLE: Think carefuily about each question before answering: Can our family take an individual for a month, a year, or longer, help him/her grow and be prepared to let him/her go? Can I spend time with the coordinator and other professionals and work cooperatively with them even when we may not agree in what is best for the individual? Am I willing to invest time and energy in helping an individual without Seeing any improvements? Am I willing to keep weekly and written records on the individual? Am I willing to limit my involvement in helping an individual as determined by agency policy and the law? Do I accept that my children might be exposed to or pick up some of the bad habits of an individual placed in my home? Do I have room in my home for the mentored client to have his/her own room? Am I willing to work with an adult of any age? would I be willing to mentored client: sacrifice the following as needed, getting to bed at a reasonablefhour? regularly scheduled home activities which have few interruptions? being able to come and go on the spur of the moment? having the house clean and neat most of the time? having company and going out regularly? the amount of time spent with biological children? YES 4.1. work with a if. to NO Which of the followin frequent and severe? types of behavior could I handle Temper tantrums ApprehensiVenESs Crying and hysterics Nightmares Finicky food habits Sloppiness and poor personal hygiene Extreme withdrawl and moodiness Wildness and running around Drug or alcohol abuse Sexual acting out Fears and phobias Depression Damaging property Overeating or constant eating Laziness and lack of cooperation Running away Stealing, lying, cheating Hurting self through pinching, cutting or scratching biting, head.banging, Wetting and soiling underpants and bed Others related to DD or SED Could I work with an individual who: 'needed to be taught through slow, each simple task? constant repetition of was bedridden was confined to a wheelchair was not able to unde 4m a?w rstand me or talk to me? even if they were NO 11 was blind or deaf? was pregnant? had problems with breathing? was severely disfigured? needed regular home injections? was an adolesoent needing help with toileting needed home changing of bandages and dressings? had a seizure disorder? was HIV or had AIDS was a "crack baby?" selfawar.qst (rev.10/21/96) le'ka IKHIHIKI