BIG BAND MUSICAL INTERVENTION
Blank Sample Form
Goals on care plan for individual residents
Resident:
1.
Goal -- Resident will show participation by:
A.
Singing
B.
Playing Instrument
C.
Other
A.
Singing
B.
Playing Instrument
C.
Other
A.
Singing
B.
Playing Instrument
C.
Other
A.
Singing
B.
Playing Instrument
C.
Other
A.
Singing
B.
Playing Instrument
C.
Other
2.
3.
4.
5.
Goal met?
Date:
6.
A.
Singing
B.
Playing Instrument
C.
Other
A.
Singing
B.
Playing Instrument
C.
Other
A.
Singing
B.
Playing Instrument
C.
Other
A.
Singing
B.
Playing Instrument
C.
Other
A.
Singing
B.
Playing Instrument
C.
Other
7.
8.
9.
10.
11.
A.
Singing
B.
Playing Instrument
C.
Other
A.
Singing
B.
Playing Instrument
C.
Other
12.
Other Comments:
Signature:
Date: