Parental Rights Waiver

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Parental Rights Waiver Powered By Docstoc
					                                              Family - Individual Supports
                                        Supplement for Children in SRS Custody
                                               Information Section
       Name:                                                                       Date:

       SRS Contact:                                                                Phone:
       Child Welfare Community Based Provider/Contractor (CWCBS):
       CWBCS caseworker?                                                           Phone:
       Child Placing Agency?                                                       Phone:
       Child Placing Agency Caseworker?                                            Phone:
       What date did they go into custody?

       Have the parental rights been severed?                          Yes              No
       Date of the current placement (resource home):
                                              Resource Family:
       Name:
       Address:
       City:                                               State:                      Zip:
       Phone:

       Is the resource family related to the child?                    Yes              No
       CDDO may request a list of former placements.
                Persons living in the resource home and relationship to resource family:
                                                       Related to Resource    Receives DD
                            Name                             Family             Services      Age
                                                            (Yes/No)               (Yes/No)




       Are any of the above persons funded with State or Medicaid Dollars (ACIL, any          Yes
       non-DD HCBS Waiver, State General Funds, and so forth)?                                No

       What is the applicant's home county CDDO?
       What is the applicant's home County?
       In which county is the applicant's Medicaid case open?
       If the current placement is not where their Medicaid case is opened, why?



       Type of placement:                             Resource               Therapeutic

       Signatures:


       Responsible Person


       Case Manager




1/08                                                                                                Page 1 of 10
                                      Family - Individual Supports Needs Assessment - Cover Sheet


Name:                                                                                      Date:
SSN:                                          DOB:                                           Age                     Tier:
                                                        Type of Request
Enchancement of Current Services                                                                               Review
Child in custody requesting SHC for reintegration                                                   Service Conversion
Child in custody requesting SHC in foster home (include Foster                                                     Crisis
Care Supplement)                                                                                   Waiting list allocation

                                                          Medicaid
Is applicant eligible for Medicaid?                              Yes                         No
If yes, fill in the number:
If applicant has recently applied, what is the date of the application?
If they have applied and been determined not eligible, please specify the reasons:



Has applicant been informed that there may be an
obligation or parental fee?
                                                                 Yes                         No
Does this person receive SSI/SSDI?                               Yes                         No
If yes, who is the payee?                                                      Amount Received?
                                                     Case Management
MR/DD TCM Name & Agency
TCM Phone Number                                                                 TCM Alternate #
                                                   Current MR/DD Funding
HCBS                                                    Day                  Residential               In Home Support

State Grant                                             Day                  Residential               Direct Financial Support
Other Funding                                           Private Pay          Discretionary             Unfunded
If Other, please describe:




                                                      Other Services:
  Please indicate what other service(s) the person is receiving below and include the case worker(s) name, agency and
                                             phone number where applicable
                            Name                                     Agency                         Phone Number
ACIL/TA

Please describe the service(s) and the number of hours per week:



                               Name                                      Agency                                Phone Number
Mental
Health
Please describe the service(s) and the number of hours per week:




    1/08                                                      Page 2 of 10
                                    Family - Individual Supports Needs Assessment - Cover Sheet

Juvenile                     Name                                       Agency                         Phone Number
Justice
System
Please describe the service(s) and the number of hours per week:




Check here (x) if these other services apply:
Foster Care for Child in SRS Custody:
Working Healthy                                                FOSTER CARE SUPPLEMENT REQUIRED
Other, please describe below:




                                                    School Services
Is applicant eligible for school services?                      Yes                     No
Is applicant home schooled?                                     Yes                     No
District:                                                      Site:                                Homebound:
Teacher:                                                             Hours/days of Attendance:
Does he/she have a current IEP?               Yes                No
 If yes, please provide a copy with this needs assessment.
Is applicant eligible for extended school year?                 Yes                     No
Anticipated graduation date:
                                               Waiting List Information
Is applicant on the waiting list?             Yes                No
If so, what is the applicant waiting for:                         Direct Financial Supports        Assistive Services
                                                               Family/ Individual Supports             Day Supports
                           Supported Employment               Personal Assistant Services        Residential Supports




     1/08                                                    Page 3 of 10
                                                             Family - Individual Supports - Needs Assessment - Sec 1 - Applicant Information

Section 1 - Applicant Information

NAME:                                                                                      DATE:
Is this applicant self-directing or planning on self-directing?                                                                                     YES      NO
If the applicant is adopted and under age 18, does the family receive an adoption subsidy?                                                          YES      NO
If Yes, what is the amount?                       $
   Persons living in the home and relationship




                                                                                            X (if Primary            Receives MR/DD Services
                                                    Name                    Relationship                       Age
                                                                                            Care Giver)                      Yes / No
                   to applicant
   providing MR/DD support




                                                                                           Live in Family
                                                    Name                    Relationship      Home?            Age                       Billing Agent/CSP
      List all individuals




                                                                                              (Y or N)
   Natural supports available-not living




                                                             Names                                  Relationship          Days of the Week          Time
             in family home




                                                                              Name                                            Time




 Volunteers available
 through an affiliation
   such as religious
 organization or club:




                                                                   Name                     Relationship       Age    Lives in family home
                                                                                                                             Yes / No
  If these are new or
additional services, who
  are you planning on
   having provide the
        services?



                   Are the services needed skilled or unskilled (see instructions):


Skilled                                          Unskilled



                                1/08                                                            Page 4 of 10
                                                                                                 Family - Individual Supports Needs Assessment - Sec. 2 Daily Activities

Name:                                                                                                                                                                                                                                                                             Date:

Day(s) of the week:

In a 24 hour period describe each activity occurring in the space provided below.
Additional sheets may be used to reflect an average week. (See instructions)


                                  1              Completely dependent                                                                                                                      Indicate if                                                 Year Round
  Level of                        2              Assistance/hands on support                                                                                                                schedule                                                   School Year
  Support                         3              Supervision (usually verbal                                                                                                                  is for:                                                  Summer
                                  4              prompts
                                                 Independent

                                  1                    2                      3                      4                        5                6                       7                         8                      9            10                                      11                                   12                                          13                 14
                                                                                                                                                                                                                                                                                                                                                            Who is
     DAILY ACTIVITIES




                                                                                                                                                                                           Community Inclusion




                                                                                                                                                                                                                                                                                          (not to exceed 60 min per hour)
                                                                                               Adaptive Equipment




                                                                                                                                         Household Services

                                                                                                                                                                  Exercise / Therapy
                                                                                                                                                                                                                                                                                                                                                                           Request for Paid




                                                                                                                                                                                                                                                                                                                            Total Minutes Required
                                                                                                                                                                                                                                                                                                                                                           Currently
                                                                                                                        Accommodations
                                                                         Medical Support
                                                  Mobility Support




                                                                                                                                                                                                                                                       Other Activity
                                                                                                                          Special Meal
                               ADL Support




                                                                                                                                                                                                                                                                                                                                                                              Supports




                                                                                                                                                                                                                                     Supervision
                                                                                                                                                                                                                                                                                                                                                           Providing




                                                                                                                                                                                                                     Transport
                                                                                                                                                                                                                                                                             Describe                                                                      Support?
                                                                                                                                                                                                                                                                               Other                                                                                    Input the number of
                                                                                                                                                                                                                                                                              Activity                                                                                  minutes requested.
                                                                                                                                                                                                                                                                                                                                                           (Enter NSN       Paid support
                                                                                                                                                                                                                                                                                                                                                         for No Support request(s) must be
                                                                                                                                                                                                                                                                                                                                                             Needed)     justified in section
Indicate Level                                                                                                                                                                                                                                                                                                                                                                     5.
  of Support

   5:00 AM                                                                                                                                                                                                                                                                                                                                           0
   6:00 AM                                                                                                                                                                                                                                                                                                                                           0
   7:00 AM                                                                                                                                                                                                                                                                                                                                           0
   8:00 AM                                                                                                                                                                                                                                                                                                                                           0
   9:00 AM                                                                                                                                                                                                                                                                                                                                           0
  10:00 AM                                                                                                                                                                                                                                                                                                                                           0
  11:00 AM                                                                                                                                                                                                                                                                                                                                           0
  12:00 PM                                                                                                                                                                                                                                                                                                                                           0
   1:00 PM                                                                                                                                                                                                                                                                                                                                           0
   2:00 PM                                                                                                                                                                                                                                                                                                                                           0
   3:00 PM                                                                                                                                                                                                                                                                                                                                           0
   4:00 PM                                                                                                                                                                                                                                                                                                                                           0
   5:00 PM                                                                                                                                                                                                                                                                                                                                           0
   6:00 PM                                                                                                                                                                                                                                                                                                                                           0
   7:00 PM                                                                                                                                                                                                                                                                                                                                           0
   8:00 PM                                                                                                                                                                                                                                                                                                                                           0
   9:00 PM                                                                                                                                                                                                                                                                                                                                           0
  10:00 PM                                                                                                                                                                                                                                                                                                                                           0
  11:00 PM                                                                                                                                                                                                                                                                                                                                           0
  12:00 AM                                                                                                                                                                                                                                                                                                                                           0
   1:00 AM                                                                                                                                                                                                                                                                                                                                           0
   2:00 AM                                                                                                                                                                                                                                                                                                                                           0
   3:00 AM                                                                                                                                                                                                                                                                                                                                           0
   4:00 AM                                                                                                                                                                                                                                                                                                                                           0
                                                                                                                                                                                                                                                                                                                                                         Total minutes
Total Minutes                                                                                                                                                                                                                                                                                                                                            should not
  Required                                                                                                                                                                                                                                                                                                                                               exceed 1440 per
                                             0                       0                     0                        0              0                          0                        0                         0               0                 0                    00                                                                           0   day.                              0
The total number of minutes for requested paid supports cannot
exceed the time eligible for services.




                        1/08                                                                                                                                                                                                     Page 5 of 10
                                Family - Individual Supports Needs Assessment - Sec. 2 Daily Activities



List Activity # and description of the service needs. Use a separate sheet of paper if necessary

 Activity #                                                        Description




        1/08                                                   Page 6 of 10
                                   Family - Individual Supports Needs Assessment - Sec 3 - Household Activity
Indicate work hours and activities other household member who live in the home (The person receiving services activities are reflected in Section
2). This should reflect an average week.

NAME:                                                                        Indicate if Year Round
DATE:                                                                        schedule is Summer
                                                                                for:
                                                                                             School Year

                               SUNDAY                                                                           THURSDAY
Relationship to                                                            Relationship to
                        Type of Activity           Start Time End Time                                     Type of Activity   Start Time End Time
  Applicant                                                                  Applicant




                              MONDAY                                                                              FRIDAY
Relationship to                                                            Relationship to
                        Type of Activity           Start Time End Time                                     Type of Activity   Start Time End Time
  Applicant                                                                  Applicant




                              TUESDAY                                                                           SATURDAY
Relationship to                                                            Relationship to
                        Type of Activity           Start Time End Time                                     Type of Activity   Start Time End Time
  Applicant                                                                  Applicant




                            WEDNESDAY
Relationship to
                        Type of Activity           Start Time End Time
  Applicant




          1/08                                                      Page 7 of 10
                      Family - Individual Supports Needs Assessment - Sec. 4 - Calculation Worksheet

Name:                                                                  Date:


                                              Requested Hours


Year Round     Minutes             School Year    Minutes                        Summer       Minutes
                 from                               from                                        from
               Section 2                          Section 2                                   Section 2

   Days                                Days                                       Days

Monday                             Monday                                      Monday
Tuesday                            Tuesday                                     Tuesday
Wednesday                          Wednesday                                   Wednesday
Thursday                           Thursday                                    Thursday
Friday                             Friday                                      Friday
Saturday                           Saturday                                    Saturday
Sunday                             Sunday                                      Sunday

  Total for            0             Total for                0                  Total for            0
   Week                               Week                                         Week
Minutes/hour          60           Minutes/hour            60                  Minutes/hour          60
Hours                  0           Hours                    0                  Hours                  0
Units/hour             4           Units/hour               4                  Units/hour             4
Units                  0           Units                    0                  Units                  0


                                            ↓↓CDDO Use Only↓↓



Year Round     Minutes             School Year    Minutes                        Summer       Minutes
                 from                               from                                        from
               Section 2                          Section 2                                   Section 2

   Days                                Days                                       Days

Monday                             Monday                                      Monday
Tuesday                            Tuesday                                     Tuesday
Wednesday                          Wednesday                                   Wednesday
Thursday                           Thursday                                    Thursday
Friday                             Friday                                      Friday
Saturday                           Saturday                                    Saturday
Sunday                             Sunday                                      Sunday

  Total for            0             Total for                0                  Total for            0
   Week                               Week                                         Week
Minutes/hour          60           Minutes/hour            60                  Minutes/hour          60
Hours                  0           Hours                    0                  Hours                  0
Units/hour             4           Units/hour               4                  Units/hour             4
Units                  0           Units                    0                  Units                  0

        Comments




 1/08                                                   Page 8 of 10
        Family - Individual Supports Needs Assessment - Sec. 5 - Justification of Requested Family - Individual Paid Support Hours

Name:                                                                   Date:
Please explain why natural supports are not sufficient to meet the needs of the applicant:



Is the applicant capable of staying home alone?             YES            NO
If yes, how long and under what circumstances?



If no, explain risks:



What training or environmental changes have been tried to reduce the risks?



What harm will come to the individual if the services requested are not available?



Any other considerations to be taken into account?



If this needs assessment is for an enhancement or crisis, what has changed that requires the need to be met differently?



What is the anticipated length of this need?



Please describe specifically how the hours requested were determined. Give details about activities of the family or needs of the
individual that helped you determine these hours. When requesting additional hours, what has changed in the person's life that requires
an increase and what will happen if the increase is not granted.




To the best of my knowledge the information in this packet is true and accurate and has been reviewed by the individual and
their support team. By signing, I understand the requested hours are subject to the approval of the CDDO.



Responsible Person



Case Manager


Documents you should provide with this request:
Person-Centered Support Plan
Behavior Support Plan - as applicable
IEP - as applicable
Treatment Plan/Plan of Care if receiving other services (ACIL/TA, Mental Health, etc.) - as applicable




1/08                                                            Page 9 of 10
            Family - Individual Supports Needs Assessment - Signature Sheet




       Responsible Party                                              Date



        Case Manager                                                  Date




1/08

				
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