Ellis Daily Care Diary Template
Purpose: Document typical day to show MD assessor time/support burden
Instructions: Fill out for 3–5 typical days between now and March 10
Day: ____ (Date)
Morning (6:00 AM – 8:00 AM)
| Time | Activity | Support Needed | Notes/Incidents |
|---|---|---|---|
| 6:45 | Waking | ☐ Physical assistance (carrying downstairs) ☐ Emotional support (tantrum prevention) ☐ Prompting |
|
| 7:00 | Breakfast | ☐ Eating prompts (# times: ) ☐ Seated reminders (# times: ) ☐ Cleanup direction |
|
| 7:25 | Dressing | ☐ Weather-appropriate choice ☐ Step-by-step prompts (# items: ___) ☐ Button/zipper help ☐ Redirection from distraction |
|
| 7:45 | Hygiene | ☐ Tooth brushing (parent-performed) ☐ Hair brushing (parent-performed) ☐ Face washing prompts |
Morning Time Burden: _____ minutes of direct support
School Day (8:00 AM – 3:00 PM)
☐ At school (supervised by teachers/therapists)
☐ Therapy today: __
☐ Incident report from school: __
Afternoon (3:00 PM – 6:00 PM)
| Time | Activity | Support Needed | Notes/Incidents |
|---|---|---|---|
| 3:00-4:00 | Snack/Free Play | ☐ Snack prompts ☐ Supervision (same floor) ☐ Independent play duration: min ☐ Redirection needed (# times: ) |
|
| 4:00-5:00 | Activity/Outing | ☐ 1:1 accompaniment required ☐ Emotional support incident ☐ Social coaching needed |
|
| 5:00-6:00 | Dinner Prep | ☐ Supervision during prep ☐ Table transition prompts |
Afternoon Time Burden: _____ minutes of direct support
Evening (6:00 PM – 9:00 PM)
| Time | Activity | Support Needed | Notes/Incidents |
|---|---|---|---|
| 6:00 | Dinner | ☐ Seated reminders (# times: ) ☐ Eating prompts (# times: ) ☐ Total reminders: ___ |
|
| 6:30-7:30 | Free Play/Screen | ☐ Supervision (same floor) ☐ Independent duration: ___ min ☐ Conflicts/meltdowns |
|
| 7:30 | Bath | ☐ Supervision ☐ Washing effectiveness check |
|
| 7:45 | Pajamas/Teeth | ☐ Dressing help ☐ Tooth brushing (parent-performed) |
|
| 8:00-9:00 | Bedtime | ☐ Parent presence required (entire time) ☐ Bedtime resistance ☐ Time to fall asleep: ___ min |
Evening Time Burden: _____ minutes of direct support
Nighttime
☐ Slept through night
☐ Woke and came to parents’ bed (time: _)
☐ Needed support during night (# times: , reason: _______)
Behavioral/Emotional Incidents
Meltdown/Shutdown/Anxiety Spike: ☐ Yes ☐ No
If yes: - Trigger: _______ - Duration: _ minutes - Intervention needed: ☐ Physical comfort ☐ Holding ☐ Co-regulation ☐ Redirection - Details: ___________
Toileting
At home: - Times used: _ - Flush prompts needed: ☐ Yes ☐ No (# times: ) - Hand-washing prompts needed: ☐ Yes ☐ No (# times: ___)
In public: - ☐ Parent accompanied to bathroom (# times: ___) - ☐ Parent in stall with him
Social/Peer Interactions
☐ No peer interaction today
☐ Supervised peer play (duration: , support needed: _)
☐ Exclusion incident: ______
☐ Conflict incident: ___________
Multi-Step Instruction Test
Instruction given: _______
Steps completed without prompting: /
Outcome: ☐ Success ☐ Partial ☐ Failed / Got distracted
Total Daily Time Burden
Direct support/supervision: _ hours minutes
Emotional regulation interventions: __ incidents, _____ total minutes
Notes for Assessor
Any additional observations or examples that demonstrate support needs:
Repeat for 3–5 days to show consistent pattern.
Updated: 2026-03-02