Form 1058 is used by a Local Intellectual and Developmental Disability Authority (LIDDA) to request a Home and Community-based Services (HCS) crisis diversion slot.
Before submitting a request, a LIDDA is responsible for determining that a person meets all the criteria and qualifications for an HCS crisis diversion slot in accordance with HHSC protocol.
When to Prepare
Following a LIDDA’s determination that a person meets all the criteria and qualifications for an HCS crisis diversion slot, the LIDDA completes the form and submits it to HHSC, along with all required supporting documentation.
The LIDDA scans the completed form and all supporting documentation and sends by secure email to LIDDARequests@hhs.state.gov. The subject line should read “Form 1058 HCS Crisis Diversion Request.”
If the LIDDA does not have access to a secure email method, the LIDDA emails HHSC at LIDDARequests@hhs.state.gov to request a secure email. The LIDDA can reply to a secure email from HHSC to submit the form.
Section 1, Local Intellectual and Developmental Disability Authority (LIDDA) Information
Date of Request — Enter the date the LIDDA staff completed the form.
LIDDA Name — Enter the name of the LIDDA.
Comp Code — Enter the component code of the LIDDA.
LIDDA Contact Person — Enter the name of the LIDDA staff who is designated as the LIDDA contact.
Email Address — Enter the email address for the LIDDA contact.
Area Code and Phone No. — Enter the area code and phone number for the LIDDA contact.
Section 2, Individual Information
Name of Person — Enter the person's full name as it appears in the Client Assignment and Registration (CARE) System.
CARE ID — Enter the CARE ID number for the person.
Date of Birth — Enter the person's date of birth.
Current Age — Enter the person's age.
Full Scale IQ — Enter the person's full-scale IQ number.
ICAP Service Level — Enter the person's Inventory for Client and Agency Planning (ICAP) Service Level number.
Address — Enter the person’s current address.
County of Residence — Enter the person’s current county of residence.
Diagnosis Information (all diagnoses, not just IDD) — Enter the person's diagnosis. List all diagnoses assigned to the person beginning with intellectual disability and developmental disabilities (IDD) diagnoses.
Reason for request — Check the appropriate box to indicate the reason for the request. If the individual lost a waiver service, specify the name of the waiver.
Organization or advocate assisting the person or LAR — Check the appropriate box (mark all that apply) if the person or legally authorized representative (LAR) is receiving assistance with this request from an advocate or organization.
Current living situation — Check the appropriate box to indicate the person's current living situation.
If in own home, family home or foster home — If the person is living in his or her own home, family home or foster home, note the following:
- Type of living situation requested — Check the appropriate box to indicate the person is requesting out of home supports or services to remain in the current home.
- Relationship of individuals living in the home — Indicate the relationship of individuals living in the home.
Waiver services currently received — Check the appropriate box to indicate the person's waiver services currently received.
Services currently received — Check the appropriate box (mark all that apply) to indicate the person's services currently received.
Other services explored — List all service attempts and provide an explanation why the service was not adequate in supporting the person.
Psychiatric and behavioral facilities admissions in past five years — List each psychiatric and behavioral facilities admission in the past five years. Enter the facility name, date of admission, reason for admission and discharge date.
Prescribed medications address — Check the appropriate box (mark all that apply) to indicate the person's reason for prescribed medications.
Communication — Check the appropriate box to indicate the person's method of communication.
Assistive devices utilized or needed (if none, specify NA)— List medical or assistive devices used or needed by the person. If none, specify NA.
Maladaptive behaviors exhibited (mark all that apply) — Check the appropriate box (mark all that apply) to indicate the person's maladaptive behaviors exhibited.
ICF search results — Check the appropriate box to indicate the ICF search results. If an ICF search was not explored, describe the reason.
Home and Community-based Services (HCS) requested — Check the appropriate box (mark all that apply) to indicate the HCS services requested.
Justification for Diversion Request — In narrative form, provide a detailed summary of the person's case and why the LIDDA believes he or she is at imminent risk of admission to an institution without services and supports through the HCS program.
Section 3, HHSC Staff Use Only — These fields are completed by HHSC staff only.