Manual Telehealth SubmissionsStaff Name(Required)Individual(Required)Staff's Email(Required) Service(Required)Community HabSupported EmploymentCall Services Used(Required)FacetimeZoomOtherWhat "Other" Call Service Was Used?Date(Required) Call Time (start)(Required) Hours: Minutes AMPM AM/PMCall Time (end)(Required) Hours: Minutes AMPM AM/PMWhat phone number did you make the call from?What phone number did you call to?Was the use of technology successful?(Required) Yes NoPhysical location of staff providing service at start time(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Valued Outcome worked on:(Required)Prompting(Required)PhysicalVerbalGesturalSupervisionIndividual Response(Required)Fully EngagedPartially EngagedRefused - Staff continued to promptService Notes(Required)Follow Up Comments
