Documents
Instructions
Updated: 11/2024
Purpose
A local intellectual and developmental disability authority (LIDDA) uses Form 1058 to request a Home and Community-based Services (HCS) crisis diversion slot.
Procedure
Before submitting a request, a LIDDA must determine a person meets all the criteria and qualifications for an HCS crisis diversion slot per HHSC LIDDA Handbook, Section 12000 Protocol for Offering an HCS Crisis Diversion Slot.
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 to HHSC. HHSC may request more information to determine all the diversion criteria is met.
Form Submission
The LIDDA scans the completed form and all supporting documentation and sends by secure email to LIDDARequests@hhs.texas.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.texas.gov to request a secure email. The LIDDA can reply to a secure email from HHSC to submit the form.
Detailed Instructions
Date of Request — Enter the date the LIDDA staff completed the form.
Section 1, Local Intellectual and Developmental Disability Authority (LIDDA) Information
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.
Area Code and Phone No. — Enter the area code and phone number for the LIDDA contact.
Email Address — Enter the email address for the LIDDA contact.
Section 2, Person Information
Person Name — 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.
Address — Enter the person’s current address.
County of Residence — Enter the person’s current county of residence.
Diagnosis Information
Suspected of having an intellectual disability or related condition? — Select Yes or No to indicate if the person is suspected of having an intellectual disability or related condition.
List known diagnoses — List all diagnoses assigned to the person beginning with intellectual disability and developmental disabilities (IDD) diagnoses.
Reason for Request — Select the reason for the request. If the person lost a waiver service, specify the name of the waiver.
Organization or Advocate Currently Assisting the Person or LAR — Check all services the person or legally authorized representative (LAR) is receiving assistance with this request from an advocate or organization.
Current Living Situation — Select the person's current living situation.
Medical or mobility assistive devices used or needed, such as wheelchair or cane. If none, specify Not Applicable — List medical or mobility assistive devices used or needed by the person. If none, specify Not Applicable.
If in own home, family home or foster home:
Type of Living Situation Requested — Select the type of living situation requested, out of home or remain in the current home.
Relationship of People Living in the Home — Indicate the relationship of people who live in the home.
Waiver Services Currently Received — Select the person's waiver services currently received.
Services Currently Received — Check all that apply to indicate the services the person currently received.
Other Services Explored — List all service attempts and explain why the service did not adequately support 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 — Select the person's reason for prescribed medications.
Communication — Select the person's method of communication.
Assistive devices used or needed for communication. If none, specify Not Applicable. — List medical or assistive devices used or needed by the person. If none, specify Not Applicable.
Maladaptive Behaviors Exhibited — Check all that apply to indicate the person's maladaptive behaviors exhibited.
Intermediate Care Facility Search Results — Check all that apply to indicate the intermediate care facility (ICF) search results. If an ICF search was not explored, explain why.
Home and Community-based Services (HCS) Requested — Check all that apply to indicate the HCS services requested.
Justification for Diversion Request — Describe in detail the current crisis and reason for the HCS crisis diversion request. Provide a detailed summary in narrative form of the person's case and why the LIDDA believes the person is at imminent risk of admission to an institution without services and supports through the HCS program.
Section 3, HHSC Staff Use Only — Only HHSC staff complete these fields.