Free Young Adolescents (Age 12 to Attainment of Age 17) - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-20851E (Rev. 08/2008)

STATE OF WISCONSIN

E. YOUNG ADOLESCENTS (AGE 12 TO ATTAINMENT OF AGE 17) Review each of the areas of functioning listed. Based on your assessment and pertinent records, determine whether or not a child has substantial limitations of functioning in a given area. If a child has substantial needs in that area, mark the box. 1. Self care - Ability to take care of personal needs and safety. Young person typically initiates and completes bathing, personal hygiene (shaves, combs hair, does own self care during menses), toilets self or manages own bowel and bladder program, is able to take own medications, dresses and undresses, and feeds self all independently or with use of adaptive devices. 2. Receptive and expressive language - Ability to communicate pragmatically to meet needs and conversationally or through signing or adaptive communication devices to exchange information or ideas in school classes, or with peers or family. 3. Learning - Ability to progress in applying the skills involved in reading, writing and mathematics; and in reasoning and problem-solving abilities. Ability to learn new skills at a pace appropriate to age. When standardized tests are used as the measure of functional abilities, a valid score that is two standard deviations below the norm for the test (e.g., an overall score of 70 on the WISC-R) will be considered a severe limitation. 4. Mobility - Ability to engage in the physical activities involved in physical education, sports, including adaptive sports, social events, and self care appropriate for age with or without the use of adaptive aids. 5. Self direction - Ability to develop friendships, relate to peer groups and to reconcile conflicts with peers or family members; to respond appropriately to authority and school rules. Young person shows concern for others, enjoys spending time with others or being alone at times, can respond to emergency situations, begins to negotiate community resources, is able to purchase from stores, vending machines, attend movies, shop for clothes, understands community safety laws. Ability to physically sustain these activities for a period of time and at a pace appropriate to age. Child understands danger and safety issues. 6. Capacity for independent living - Ability to live without extraordinary assistance. Ability to function in cognitive, communicative, motor, social, personal/behavioral domains; and have the concentration, persistence, and pace to complete age-appropriate tasks. Young person is able to plan and prepare a meal independently, or with adaptive devices, shop for food and other needs, manage own money, pay bills, maintain a checking account, clean house, do laundry. 7. Economic self-sufficiency - Ability to function in school, vocational programs, part-time or full-time work and organized activities. Young person is able to seek employment and participate in work activities for wages.