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Downloading a Form to Your Computer
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To provide a standardized record of determining whether an applicant or individual is appropriate for Adult Foster Care (AFC) based on the applicant's/individual's condition and behavior. Also, to develop a service plan appropriate to the applicant's/individual's needs and specific to a given provider, taking into consideration the provider's capabilities.
When to Prepare
The case manager completes this form before certifying an individual eligible for AFC, including emergency care placements. The case manager updates the form when changes occur in the individual's condition. A new form is completed at each annual reassessment.
The AFC provider completes the form to assess the appropriateness of a private pay individual in the certified AFC home and submits to the contract manager for review.
The case manager keeps the original in the case record and sends one copy to the AFC provider.
The AFC provider keeps one copy and sends the original to the contract manager.
Keep the original in the case record for three years after the case is closed.
Date of Completion— Enter the date the form is completed.
Update— Enter the date the form is updated for a change or other event.
Type of Assessment— Check the appropriate box for the type of assessment.
Date of Entry— Enter the date the individual entered the home or the proposed date of entry, if known.
Applicant/Individual Name— Enter the individual's name.
Individual No.— Enter the individual's number, if available.
Score— Enter the Form 2060, Needs Assessment Questionaire and Task/Hour Guide, score of the applicant/individual. (N/A for private pay individuals.)
Provider Name/Address/Telephone No.— Enter the AFC provider's name, address and telephone number.
Based on the individual's functional assessment, additional interviews and observation, mark all appropriate or inappropriate characteristics to assess if the individual is appropriate for foster care.
Tasks— To indicate the individual needs assistance with tasks, check the appropriate boxes.
Additional Description of the Individual's Needs/Comments
Enter a brief description of the individual's functional ability regarding the tasks and the type of assistance the AFC provider will be required to provide.
Changes Since Last Assessment— Use this section for interim updates and when assessing a change in the individual's functional abilities. Date and initial the entry.
Additional Information About the Individual
Use this section to describe the individual's health and physical problems, list medications taken, describe the individual's behavioral and mental health problems, and to document the individual's background and family resources. Enter any information that is relevant to the individual's placement in AFC and will be useful in assisting the individual in making a successful transition to AFC.
Additional Tasks Authorized— Check additional tasks based on the individual's needs with a brief explanation on why the task is being authorized.
Provider's Signature/Date— The provider signs and dates the form.
Update Provider's Signature/Date— The provider signs and dates the form for a change in the assessment or service plan.
Case Manager's Signature/Date— The case manager signs and dates the form.
Update Case Manager's Signature/Date— The case manager signs and dates the form for a change in the assessment or service plan.
Approval of Adult Foster Care and the Service Plan
Section I. Supervisory Approval— The case manager's supervisor reviews all information on the form and if the applicant/individual is appropriate for AFC, the supervisor signs and dates the form. If the supervisor is at a different location and not available for reviewing the form in person, the form may be mailed or faxed to the supervisor for review. The supervisor may give approval by telephone. The case manager checks the telephone approval box and enters the date.
Telephone Approval— If supervisor approves AFC by telephone, check the telephone approval box and enter the date of verbal approval.
Update— If there is an interim change in the individual's assessment but the individual continues to be appropriate for AFC, the supervisor signs and dates the update.
Section II. Supervisory Disapproval— The case manager's supervisor reviews all information on the form and if the applicant/individual is not appropriate for AFC, the supervisor documents the reasons the applicant/individual is not appropriate and signs and date the form. If the supervisor is at a different location and not available for reviewing the form in person, the form may be mailed or faxed to the supervisor for review. The supervisor may give disapproval by telephone. The case manager checks the telephone contact box and enters the date.
Section III. Contract Manager Approval for Private Pay— The contract manager reviews, signs and dates the form if a private pay individual meets the criteria for appropriate characteristics and is approved to move in or remain in the AFC home.
Section IV. Contract Manager Disapproval for Private Pay— The contract manager reviews all the information on the form and if the individual is not appropriate for AFC, the contract manager documents the reason the individual is not appropriate and signs and dates the form. If the contract manager determines that the individual is not appropriate, the individual is not approved to move in or remain in the AFC home.