Please fill out the entire form...
Section I - Individual's Contact Information
Last Name:
First Name:
TABS Number:
Sex:
Date of Birth:
(entered as #/#/####)Invalid Date Format
Medicaid Number:
Street:
City:
State:
Zip:
Phone:
Email:
No Email:
Section II - Current Living Situation
With Family:
On Own:
ISS:
IRA:
Other Living Situation:
Section III - Current Situation
Imminent or Increasing Risk Of:
Caregiver is Single:
Caregiver is age 65 Plus:
Caregiver's Health and Wellness impacts their ability to support the person:
Person's needs are impacting the Health and Wellness of the Caregiver:
Multiple Family Members with Complex Needs:
Section IV - Ambulation
Ambulatory:
Difficulty With Stairs:
Requires Lifting:
Requires Assistance To Transfer:
Requires Wheelchair, Scooter or Other For Distances:
Uses a Walker, Cane Or Other:
Section V - Communication
Communication Select One:
Section VI - Primary Language if Not English
American Sign:
Spanish:
If Other Please Specify:
Section VII - Qualifying Development Disability Diagnoses & Associated Conditions(select all that apply)
18Q Syndrome:
Angelman Syndrome:
Ataxia-Telangiectasia:
Autism Spectrum Disorder (includes Asperger, PDD, Autism):
Beckwith-Wiedemann Syndrome:
Cerebral Palsy:
Charge Syndrome:
Chiari Malformation:
Childhood Disintegrative:
Cornelia de Lange Syndrome:
Cri-du-chat Syndrome:
Dandy Walker Syndrome:
Down Syndrome:
Familial Dysautonomia:
Fetal Alcohol Syndrome:
Fragile X:
Friedreich Ataxia:
Klinefelter Syndrome:
Landau Kleffner Syndrome:
LCHAD (Long Chain Acyl CoADehydroenose Deficiency):
Intellectual Disability (IQ below 69):
IQ of 50+:
IQ of 50-:
Prader-Willi:
Robinow Syndrome:
Rett Syndrome:
Rubenstein Taybi Syndrome:
Seizure Disorder:
Severe Juvenile Arthritis:
Spina Bifida:
Tay-Sachs Disease:
Tourette Disorder:
Traumatic Brain Injury:
Turner Syndrome:
Williams Syndrome:
Other Developmental Disabilities, Please Specify:
Section VIII - Problem Behaviors-
If Yes, May Engage in These Problem Behaviors
Destroys Property:
Eats Inedible Objects:
Inappropriate Personal Boundaries:
Inappropriate Sexual Behavior:
Self Injury:
Smears Feces:
Tantrums Or Emotional Outbursts:
Verbal Aggression/Abuse, Argumentative:
Elopes/Bolts Away From Supervision:
Wanders Away From Supervision:
Bites:
Kicks:
Hits:
Punches:
Scratches:
May Engage In These Problem Behaviors-Other:
Medication Taken to Manage Problem Behavior:
Section IX - Behavioral Health Conditions-
, If yes...
At Least One Current Mental Health Diagnosis:
Medication Taken To Manage Symptoms:
At Least One Current Substance Use/Abuse Diagnosis:
Medication Taken To Manage Substance Abuse:
Section X - Prominent Physical/Health/Medical Conditions, Concerns, Alerts
Prominent Physical/Health/Medical Condition Concerns Alerts-None?:
Allergies:
Anaphylaxis:
Asthma:
Catheter:
Choking Risk:
Cardio-Vascular:
Diabetes:
Gastrointestinal:
Hearing Impairment:
Hypertension:
Obesity:
Oxygen Dependent:
Problems With Toileting Elimination:
Requires Specialized Feeding:
Respiratory:
Sleep-Wake Issues:
Vision Impairment:
Seizure Disorder/Epilepsy:
Prominent Physical/Health/Medical Conditions, Concerns, Alerts, Other, Please Specify:
Medication Taken To Manage Physical/Health/Medical Conditions:
Section XI - Current Services Authorized and Receiving
For "Currently Provided" indicate 0 if receiving no services and if partially served, indicate the number of units receiving.
*If partially served, complete the following
NOTE: 1 Unit = 15 Minutes
Community Habilitation:
Current CH Provider:
CH Approved Units:
per week CH Currently Provided Units:
per week NOTE: 1 Unit = 15 Minutes. The number of approved units and provided units must be entered.
Respite:
Current Respite Provider:
Respite Approved Units:
per week Respite Currently Provided Units:
per week NOTE: 1 Unit = 15 Minutes. The number of approved units and provided units must be entered.
CHCIHS:
CHCIHS Approved Units:
per week CHCIHS Currently Provided Units:
per week NOTE: 1 Unit = 15 Minutes. The number of approved units and provided units must be entered.
CHCIHS In Process:
CH-R:
CH-R Approved Units:
per week CH-R Currently Provided Units:
per week NOTE: 1 Unit = 15 Minutes. The number of approved units and provided units must be entered.
Day Habilitation:
Family Support:
In-Home Behavior Consultation:
IBS:
IRA:
ISS:
OASAS:
OMH:
Self Direction:
START:
Supported Employment:
Current Services Notes:
Section XII - If Registered as a Student with a School District. Please complete this section.
School District:
Placement If Out Of District:
Service OT:
Services PT:
Services Speech:
Services ABA:
Services Counseling:
Provisional OPWDD Eligibility:
If Yes, Eligibility Expiration Date:
(entered as #/#/####)Invalid Date Format
Section XIII - Family Contact
Family Contact1 Name:
Family Contact1 Relationship:
Family Contact1 CustodialParent:
Family Contact1 LegalGuardian:
Family Contact1 Street:
Family Contact1 City:
Family Contact1 State:
Family Contact1 Zip:
Family Contact1 Phone:
Family Contact1 Cell:
Family Contact1 Email:
Family Contact1 No Email:
Family Contact2 Name:
Family Contact2 Relationship:
Family Contact2 Custodial Parent:
Family Contact2 Legal Guardian:
Family Contact2 Street:
Family Contact2 City:
Family Contact2 State:
Family Contact2 Zip:
Family Contact2 Phone:
Family Contact2 Cell:
Family Contact2 Email:
Family Contact2 No Email:
Section XIV - Care Manager
Agency Name:
Care Manager (MSC):
Care Manager Phone:
Care manager Email:
Care Manager Supervisor's Name:
Care Manager Supervisor's Email:
Section XV - Sensitive Information-Please Be Brief or Submission May Not Come Through
Sensitive Information:
Section XVI - Preferences, Special Requests and Other Factors That Could Impact the Staff Matching Process
Active Household Members May Disrupt Service:
Age Preference:
Family Dynamics:
Gender:
Service Location:
Home Environment, Animals, Reptiles, Insects:
Home Environment-Space Limitation:
Language:
Neighborhood and/or Building Safety:
Non-Smoking Staff:
Peer Role Model:
Religion/Cultural Considerations:
Smoking Household:
Open to working with any of the six participating providers:
Provider Preference:
Provider Exclusion:
If Yes, please list below
Other Factors That Could Impact The Staff Matching Process:
Section XVII - Attestation
By submitting this form you are attesting that you have reviewed with the individual/family/caregiver the options for connecting with community supports and they have chosen to participate in the OCCSI. A signed Authorization for Release of Health Information form and other required supporting documentation has been filed with the Department of Mental Health. Release Signature Date:
Required Field
Invalid Date Format
I N T E R N A L U S E O N L Y
Status:
Support Suggested:
Comments:
Last Saved By:
TimeStampEntered:
To Print- Click File Print on your web browser, use Control-P or right click the page to print out the form
Insert
Cancel
|