Form 1058, Request for Home and Community-based Services Crisis Diversion Slot

Instructions for Opening a Form

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Effective Date
01/2021
1058.pdf (118.8 KB)

Instructions

Updated: 1/2021

Purpose

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.

Procedure

Before submitting a request, a LIDDA is responsible for determining that an individual meets all of the criteria and qualifications for an HCS crisis diversion slot in accordance with HHSC protocol.

When to Prepare

Following a LIDDA’s determination that an individual meets all of 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.

Form Submission

The LIDDA scans the completed form and all supporting documentation and sends by secure email to LiddaRequests@hhsc.state.tx.us. 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@hhsc.state.tx.us to request a secure email. The LIDDA can reply to a secure email from HHSC to submit the form.

Detailed Instructions

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

Individual Name — Enter the individual’s full name as it appears in the Client Assignment and Registration (CARE) System.

CARE ID — Enter the CARE ID number for the individual.

Date of Birth — Enter the individual’s date of birth.

Current Age — Enter the individual’s age.

Full Scale IQ — Enter the individual’s full-scale IQ number.

ICAP Service Level — Enter the individual’s Inventory for Client and Agency Planning (ICAP) Service Level number.

Diagnosis Information (all diagnoses, not just IDD) — Enter the individual’s diagnosis. List all diagnoses assigned to the individual 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 individual/LAR — Check the appropriate box (mark all that apply) if the individual/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 individual’s current living situation.

If in own home, family home or foster home — If the individual is living in his/her own home, family home or foster home, note the following:

  • Type of living situation requested — Check the appropriate box to indicate the individual 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 individual’s waiver services currently received.

Services currently received — Check the appropriate box (mark all that apply) to indicate the individual’s services currently received.

Other services explored — List all service attempts and provide an explanation why the service was not adequate in supporting the individual.

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 individual’s reason for prescribed medications.

Communication — Check the appropriate box to indicate the individual’s method of communication.

Assistive devices utilized or needed (if none, specify NA)— List medical/assistive devices used or needed by the individual. If none, specify NA.

Maladaptive behaviors exhibited (mark all that apply) — Check the appropriate box (mark all that apply) to indicate the individual’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 individual’s case and why the LIDDA believes he/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.