Form 4120-2025

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The document is a Day Habilitation Service Delivery Log from the Texas Department of Aging and Disability Services, designed for tracking the services provided to individuals in home and community-based settings. It includes sections for recording individual names, service dates, times of service, areas of assistance provided, staff initials, and comments on special events or occurrences.

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Click ‘Get Form’ to open form 4120 in the editor.
Begin by entering the individual’s name in the 'Individual Name' field at the top of the form. This is essential for identifying the service recipient.
Fill in the 'Place of Service(s)' section to specify where the services were provided.
For each day of the week, enter the date in 'mm/dd/yy' format and record 'Time In' and 'Time Out' for each session.
Mark (initial or check) all areas where assistance was provided throughout the week, ensuring accurate documentation of services rendered.
In the 'Comments' section, note any special events or occurrences that may be relevant to service delivery.
Finally, have staff members sign and initial as required, including their Staff ID for verification purposes.

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