Form 8577, Questionnaire for LTSS Waiver Program Interest Lists

Instructions

Updated: 9/2023

Purpose

Form 8577, Questionnaire for LTSS Waiver Program Interest Lists is used to gather supplemental information on individuals requesting to be registered on any Long-term Service and Supports (LTSS) waiver program interest list managed by the Texas Health and Human Services (HHS) or the Local Intellectual and Developmental Disability Authority (LIDDA).

Note: Community Services (CS) manages Title XX programs, known as Regional Community Services programs, which do not require completion of Form 8577.

Procedure

When to Prepare

Interest List Management (ILM) staff complete the form electronically in the Community Services Interest List (CSIL) system before placing an individual’s name on the Community Living Assistance and Support Services (CLASS) program, Medically Dependent Children Program (MDCP), Deaf Blind with Multiple Disabilities (DBMD) program interest list(s), or STAR+PLUS Home and Community Based Services (HCBS).

LIDDA staff complete the form electronically in CSIL before placing an individual’s name on the Home and Community-based Services (HCS) program or Texas Home Living (TxHmL) program interest list(s).

Transmittal

Data collected from the completed form is manually entered into CSIL by Interest List Management and LIDDA staff.

Form Retention

An electronic copy of the form is retained in the CSIL database for each individual placed on the CLASS, DBMD MDCP, STAR+PLUS, HCS and TxHmL interest lists.

Detailed Instructions

Completed By: CSIL auto-populates the name of the HHS/LIDDA system user completing the form.

Date Completed: CSIL auto-populates the current date of completion.

Employee ID: CSIL or CARE auto-populates the employee identification number of the HHS/LIDDA staff completing the form.

Individual's Name: CSIL auto-populates the individual's name who is being placed on the interest list (IL).

Social Security No.: CSIL auto-populates the individual's Social Security number, if available.

Date of Birth: CSIL auto-populates the individual's date of birth.

CSIL ID: CSIL auto-populates the individual's CSIL identification number.

CARE ID: CARE auto-populates the individual's CARE identification number, if available.

Name of Person Providing Information: CSIL auto-populates the individual's name if self, parent, guardian or legally authorized representative (LAR) is selected as the relationship to the individual. Enter the name of the person supplying the information on the questionnaire, if other than the individual seeking services.

Relationship to Individual: Select the relationship to the individual seeking service of the person supplying the information. If self is selected, CSIL populates the individual’s name, address, phone number, email address and mobile phone number. If parent, guardian or LAR is selected, CSIL populates the individual’s address and phone number.

Mailing Address: CSIL auto-populates the individual's mailing address, city, state and ZIP code if self, parent, guardian or LAR is selected as the relationship to the individual seeking services. Enter or change the mailing address, city, state and ZIP code for the individual providing information, if different from the individual seeking services.

Primary Area Code and Phone No.: CSIL auto-populates the individual's area code and phone number if self, parent, guardian or LAR is selected as the relationship to the individual seeking services. Check the box if phone number is a cell phone.

Physical Address: CSIL auto-populates the person’s mailing address, city, state and ZIP code if self, parent, guardian or LAR is selected as the relationship to the person seeking services. Enter or change the mailing address, city, state and ZIP code for the person providing information, if different from the person seeking services. Check box if physical address is same as mailing address.

Email Address: CSIL auto-populates the individual’s email address, if self, parent, guardian or LAR is selected as the relationship to the individual seeking services.

Secondary Area Code and Phone No.: CSIL auto-populates the individual's area code and phone number, if self, parent, guardian or LAR is selected as the relationship to the individual seeking services. Check the box if the phone number is a cell phone.

Residence County: CSIL auto-populates the name of the county the individual lives in. You may update if the individual will be receiving services in a county different from the mailing address county.

Medicaid No.: CSIL auto-populates the individual’s Medicaid number, if available.

Gender: Check the box that represents the gender of the individual.

Alternate Contact Name: Provide the name of an alternate contact to help aid you with your interest list record.
Alternate Contact Relationship: Provide the relationship of the alternate contact to help assist you with your interest list record.

Alternate Contact Relationship to Individual: Provide the relationship of the alternate contact to help assist you with your interest list record.

Alternate Contact Email Address: Provide the email address of the alternate contact to help assist you with your interest list record.

Alternate Contact Phone No.: Provide the phone number of the alternate contact to help assist you with your interest list record. Check the box if the phone number is a cell phone.

Second Alternate Contact Name: Provide the name of a secondary alternate contact to help assist you with your interest list record.

Second Alternate Contact Relationship to Individual: Provide the relationship of the secondary alternate contact to help assist you with your interest list record.

Second Alternate Contact Email Address: Provide the email address of the secondary alternate contact to help assist you with your interest list record.

Second Alternate Contact Phone No.: Provide the phone number of the secondary alternate contact to help assist you with your interest list record. Check the box if the phone number is a cell phone.

Does the individual have a Child Protective Services (CPS) or Adult Protective Services (APS) conservatorship? Select yes or no. If yes, add at least one alternate contact (e.g., caseworker, CASA contact or other contact) and list conservatorship county.

Decline to answer questionnaire items: Check this box if the individual or the person providing information indicates he or she does not want to answer the questions. If the individual seeking services or the person supplying information says he or she does not want to answer the questions, enter a comment in the box below.

Comments: Provide additional comments (for example, declines because the information is unknown).

1. Does the individual have a diagnosis for intellectual disability or developmental disability before 18 years? — Select Yes, No or Unknown. List diagnosis: — List the diagnosis in the open text box or leave it blank if no diagnosis exists. 

2. Does the individual have a developmental disability that presented before 22 years? — Select Yes, or No. Check all that apply: Select applicable boxes.

3. Does the individual have a vision or hearing impairment? — Select if the individual has a vision or hearing impairment, or both.

4. Does the individual have a chronic medical condition? — Select Yes, or No. Check all that apply: Select applicable boxes. 

5. Does the individual have a mental or behavioral health diagnosis? — Select Yes or No. Check all that apply: Select applicable boxes.

6. What are the individual’s current living arrangements? — Check all that apply: Select applicable boxes.

7. Are there existing circumstances that may cause loss of individual’s current care giver supports? — Select Yes or No. Explain or enter N/A in the open text box.

8. Does the individual want to live independently? — Select Yes or No. If yes, explain.

9. If the individual loses their caregiver supports or living arrangement within the next year, is there a back-up plan of where the individual will live and who will be the caregiver? — Select Yes or No. If yes, explain.

10. Does the individual need assistance with the current living arrangement? — Select Yes or No. Check all that apply: Select applicable boxes. If other is selected, explain the type of communication help needed.

11. Does the individual need help with personal care tasks? Select Yes or No. Check all that apply:— Select applicable activity(ies) of daily living. If other is selected, explain the type of personal care needed.

12. Does the individual need help with communicating? Select Yes or No. Check all that apply: Select applicable boxes. If other is selected, explain the type of communication assistance needed.

For Methods Used, select: Braille, Sign Language or Other, if applicable.

13. Does the individual need help with walking or other mobility assistance? Select Yes or No. Check all that apply: —Select applicable boxes. If other is selected, explain the type of mobility assistance needed.

14. Are there any barriers to accessing services? — Select Yes or No.

A.    What barriers to services does the individual have? Check all that apply: Select applicable boxes. If other is selected, explain other transportation barrier(s).

B.    Does the individual have access to the following transportation options? Check all that apply: Select applicable boxes. If other is selected, explain other barrier(s).

15. Does the individual need community integration assistance? —Select Yes or No. Check all that apply. If yes, select applicable boxes. If skills training is selected, explain the type of skills training needed.

16. Does the individual need life skills training (examples: time management, decision making, communication, budgeting or preparing meals)? —Select Yes or No. If yes, select applicable boxes. If skills training is selected, explain the type of life skills training needed.

17. Does the individual need employment or vocational services? —Select Yes or No. If yes, select applicable boxes. If skills training is selected, explain the type of job skills training needed.

18. Is the individual currently receiving other community services? — Select all that apply. Check Unpaid caregivers if the individual is receiving assistance from family, friends, neighbors or church members. If other is selected, explain other service(s) the individual receives.

19. In your opinion, when should waiver services begin to ensure the individual’s health and welfare? — Select the applicable box.

20. Comments — Add additional comments, as needed. 

Referral made to: Check all that apply — Select applicable boxes. If other is selected, explain other program(s). Section to be completed by HHSC or LIDDA staff.