RA Monthly Note

"*" indicates required fields

Client Full Name:*

First Name Last Name

Month/Year*

Recovery Aide (RA) Full Name:*

Agency Name:*

Level of Assistance: (LOA)*

5 = Maximum Assistance
4 = Moderate Assistance
3 = Minimum Assistance
2 = Stanby Assistance
1 = Independent
0 = Client chose not to participate in activity
N/A = Activity did not occur/did not need to occur

Please provide the LOA Provided for the Activities Below: Month Day Year June 23 2025

Personal Hygiene:

Focus on Recovery: (Y/N)

Comments:

Household Task:

Focus on Recovery: (Y/N)

Comments:

Personal Laudry:

Focus on Recovery: (Y/N)

Comments:

Food Management:

Focus on Recovery: (Y/N)

Comments:

Personal Health & Safety:

Focus on Recovery: (Y/N)

Comments:

Budgeting:

Focus on Recovery: (Y/N)

Comments:

Leisure Activities:

Focus on Recovery: (Y/N)

Comments:

Transportation:

Focus on Recovery: (Y/N)

Comments:

Interpersonal Skills:

Focus on Recovery: (Y/N)

Comments:

Summary:

Hospitalization or 911 Call?

Yes

Date of Hospitalization or 911 Call:

Name of Hosptial/Location:

RA Signature*

Date*

RA Monthly Note

Level of Assistance: (LOA)*

Please provide the LOA Provided for the Activities Below: Month Day Year June 23 2025

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