Acting Commissioner Kristin M. Woodlock, RN,
MPA
Governor Andrew M. Cuomo
Home and Community Based Services Waiver
and Safety Plan Contract
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| These are the things that usually make me most upset: |
This is what I do when I start feeling upset: |
The best things for me to do to stop feeling upset are: |
When I feel upset, the people I would like to talk to or be with are: |
When I am upset, I wish people would: |
I agree that I will try my best to do the things that make me feel better, when I first notice that I am starting to feel upset.
| Required Signatures | |||
| Child: | Date: | ||
| Parent: | Date: | ||
| ICC: | Date: | ||
| Teacher (if school is involved: | Date: | ||
Rev.5/10
Comments or questions about the information on this page can be directed to the Home and Community Based Waiver Program.