DADS/HHSC

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					Texas Department of Aging                                                                                                                                                                                                                                                                                                       Form 8576
and Disability Services                                                                                                                                                                                                                                                                                                          April 2012
Provider Name                                                                                                                                                                     Comp Code                                                 Contract No.



                                                                                                    Individual Profile Information
                                                                                                                                                      Day Activity
                                        Legal Status                                                                                               (Mark all that apply)                                                                                                           (Mark all that apply)




                                                                                                                    Residential Support
                                                                                                                                                                                                                           Special Needs:




                                                                                                                    RSS, SL, FC, OHFH




                                                                                                                                                                                                                                                                                                                                                Rights restriction?
                                                                    Adult, no guardian




                                                                                                                                                                                                                                                                      Visually impaired?

                                                                                                                                                                                                                                                                                           Hearing impaired?
                                                Adult, w/guardian




                                                                                                                                                                                                                                                   manages finances
                                                                                                                                                                                                                            (Be Specific)




                                                                                                                                                    Day Habilitation




                                                                                                                                                                                                                                                   Mark if provider
                                                                                                                                                                                                 No Day Activity




                                                                                                                                                                                                                                                                                                               Behavior plan?
                                                                                                                                                                                                                    Example: Does the consumer




                                                                                                                                                                                                                                                                                                                                 Psychotropic
                                                                                                                                                                                                                      have any medical needs?




                                                                                                                                                                       Employed
                                                                                                                                                                                                                          Adaptive aids?




                                                                                                                                          School
                                                                                                                                                                                                                          Health issues?




                                                                                                                                                                                                                                                                                                                                 meds?
                                                                                                                                                                                  DAHS
                                        Minor




                                                                                                                                                                                         Other
                                                                                                                                                                                                                       Medical or psychiatric
      Individual’s Name     Age   LON                                                    LAR’s Name/Telephone No.                                                                                                           diagnoses?




Form Completed By:                                                                                                                                                                                                 Date:

				
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