Family Living Staff Time Sheet

For the Month of: _________________________________, 20_______________

Family Living Staff Name: ________________________________________________________________________

Last First

Family Living Consumer Name: ___________________________________________________________________

Last First

Address: _____________________________________________________________________________________

Street City

Phone: _____________________________________________________________________________________

Date Care Began

Date Care Ended

Total Days of Care

**PLEASE NOTE: The Family Living may not be billed when an individual is hospitalized or in an institutional care setting**

Training Hours Completed this month: _______________________________________________________________

(Documentation must be attached IF Training was not at La Vida Felicidad)

______________________________________________________________ ____________________________

Family Living Staff Signature Date Signed

______________________________________________________________ ____________________________

LVF Authorized Signature Date Signed