Form 2356, Referral for HCS Aging Out of CPS Conservatorship Slot

Instructions

Updated: 8/2024

Purpose

Child Protective Services (CPS) uses Form 2356 to refer a person to a Home and Community-based Services (HCS) Aging out of Child Protective Services Conservatorship (AOC) Slot.

Criteria and Qualifications for an HCS AOC Slot:

• Person is suspected of having an intellectual disability or HHSC-approved related condition.
• Person is age 16 and older aging out of CPS conservatorship, regardless of residential location.

Procedure

Before submitting a request, CPS must determine if the person meets the criteria and qualifications for an HCS AOC slot.

When to Prepare

Following CPS’s determination that a person meets all criteria and qualifications for an HCS AOC slot, CPS completes the form and submits it to HHSC with all required supporting documentation.

Form Submission

The CPS State Office Developmental Disability (DD) Specialist must authorize the form in Section 3 before submission. CPS scans the completed form and sends by secure email to LIDDARequests@hhs.texas.gov. The subject line must read Form 2356 HCS AOC Referral.

Incomplete forms or forms not authorized by the CPS State Office DD Specialist will be returned unprocessed.

If CPS does not have access to a secure email, CPS can email HHSC at LIDDARequests@hhs.texas.gov to request a secure email. HHSC will email CPS using a secure email and CPS can reply with the form and supporting documentation if applicable.

Detailed Instructions

Section 1, Child Protective Services (CPS) Information

Date of Request — Enter the date the CPS staff completed the form.

When is the slot needed — Check the appropriate box to indicate when the slot is needed.

Regional Developmental Disability (DD) Specialist’s Name — Enter the name of the CPS Regional DD specialist.

Regional DD Specialist’s Area Code and Phone No. —Enter the area code and phone number of the Regional DD Specialist.

Regional DD Specialist’s Email Address — Enter the email address of the Regional DD Specialist.

Regional DD Specialist’s Address — Enter the address of the Regional DD Specialist.

Involved Local Intellectual and Developmental Disability Authorities (LIDDAs) Names — List the name of all LIDDAs that have been involved with the person in conjunctions with CPS.

Available Testing — Check all tests CPS has available on the individual. If Other selected, list all tests CPS has.

Section 2, Person’s Information

Person’s Name — Enter the person’s full name.

Person ID — Enter the person’s CPS Person ID number.

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

Age — Enter the person’s current age.

Medicaid No. — Enter the person’s Medicaid number.

Social Security No. — Enter the person’s Social Security number.

Gender— Check the gender the person identifies as. If Other selected, enter how the person identifies.

History of Intellectual or Developmental Disability —Check the appropriate box. If Yes, enter the person’s IQ.

Diagnosis Information — Enter all diagnoses assigned to the person, beginning with the IDD diagnosis.

Current Placement Name — Enter the name of the person’s current placement.

Current Placement Address — Enter the address of the current placement.

Current Placement County — Enter the county of the current placement.

Current Placement Type — Check the appropriate box to indicate the type of current placement.

Legal County — Check the appropriate box to indicate the legal county of conservatorship or guardianship. Enter the county name if the person is under conservatorship or guardianship.

Is placement desired in a certain area of the state — Check the appropriate box to indicate if the person’s placement is desired in a specific area of the state, such as near relatives. If Yes, enter the county of preference.

Guardianship Status — Check all appropriate boxes that apply about the person’s guardianship. If appropriate, provide more comments for clarity.

Name of Guardian if guardianship has been granted — Enter the name of the person’s guardian if applicable. Do not list the CPS worker.

Agency Name or Relationship of Guardian — Enter the agency or relationship of the guardian.

Guardian Area Code and Phone No. — Enter the guardian’s phone number.

Guardian’s Address — Enter the guardian’s address.

If the person is not likely to have a guardian at age 18, does the person have someone who will help in decision making about HCS enrollment and provider choice? – Check the appropriate box to indicate if the person has someone who will help them in decision making who is not a guardian. If Yes, enter the name of the person.

Special Issues — Enter any more relevant information about the person and the services they may need.

Section 3 — Required CPS State Office DD Specialist Information and Authorization

CPS State Office DD Specialist’s Printed Name — Enter the CPS State Office DD Specialist's name.

CPS State Office DD Specialist’s Signature — The CPS State Office DD Specialist signs the form.

Date — Enter the date the CPS State Office DD Specialist signs the form.

CPS State Office DD Specialist’s Area Code and Phone No. — Enter the CPS State Office DD Specialist area code and phone number.

CPS State Office DD Specialist’s Email — Enter the CPS State Office DD Specialist's business email address.

Section 4, HHSC Staff Use Only — These fields are completed by HHSC staff only.