Form 3657, Pre-Enrollment Assessment

Effective Date
08/2015
Document
Document
3657.pdf (130.25 KB)

 

Instructions

Updated: 8/2015

 

Purpose

To record relevant and current pre-enrollment assessment information about a Community Living Assistance and Support Services (CLASS)/Community First Choice (CFC) applicant.

 

Procedure

When to Prepare

The CLASS/CFC case manager completes this form at the time of the initial face-to-face meeting with the applicant/legally authorized representative (LAR) after receipt of faxed notification from HHSC CLASS state office that the applicant/LAR has selected local catchment area case management and direct services agencies.

The initial face-to-face meeting by the case manager must be conducted within 14 calendar days of fax notification from HHSC state office; if the initial face-to-face meeting cannot be held within 14 calendar days, the case manager must document in the applicant's record the reason(s) why the meeting was not held within this required time frame.

Transmittal

The completed form is filed in the applicant's case record by the case manager. The case manager submits a copy of the completed form to the direct services agency selected by the applicant/LAR, and to the applicant/LAR.

Form Retention

Keep this form according to record retention requirements documented in the CLASS Provider Manual.

 

Detailed Instructions

A. Applicant Information

Name — Enter the applicant's full name (last, first, middle initial) as shown on

  • Medicaid Identification (Form 3087); or
  • Social Security card; or
  • the full name as provided by the applicant/LAR.

Date of Birth — Enter the date of the applicant's birth, using eight digits, following the sequence month, day, year (mm/dd/yyyy).

Place of Birth (if applicable for eligibility) — Enter the applicant's place of birth (city, state, ZIP code), if applicable for eligibility determination.

Mailing Address (Street and/or P. O. Box, City, State, ZIP Code) — Enter the applicant's mailing and/or post office address (city, state, ZIP code) in the CLASS catchment area.

Social Security No. — Enter the applicant's nine-digit social security number.

Medicaid No. (9 digits) — Enter the applicant's nine-digit Medicaid number. If no Medicaid number, enter N/A.

Medicare No. (9 digits, if applicable) — Enter the applicant's nine-digit Medicare number, if applicable. If not applicable, enter N/A.

Private Insurance (name and group no., if applicable) — Enter the name and group policy number of the applicant's/LAR's private insurance company, if applicable. If not applicable, enter N/A.

Legal Status — Enter the legal status of the applicant: minor, adult, LAR, his own guardian, or other (such as medical power of attorney, partial guardianship, ward of state, etc.).

Living Arrangement — Enter the living arrangement of the applicant: lives with parent/LAR, alone, with spouse, with other relative, with roommate, or other (specify).

Diagnosis — Enter information provided by applicant/LAR regarding all current diagnoses.

B. LAR/Primary Correspondent Information

Name — Enter the contact name(s) of the applicant's LAR/primary correspondent.

Relationship(s) to Applicant — Enter the relationship of the correspondent to the applicant (examples: guardianship, power of attorney or legal representative of the applicant).

Address (include City, State and ZIP Code) — Enter the address of the applicant's LAR/correspondent, including city, state and ZIP code.

Home Area Code and Telephone No. — Enter the home telephone number of the applicant's LAR/correspondent. Include the area code.

Work Area Code and Telephone No. — Enter the work telephone number of the applicant's LAR/correspondent.

C. Sibling/Dependents Information

Name — Enter the names of all siblings or dependents of the applicant.

Date of Birth — Enter the date(s) of birth for each sibling or dependent of the applicant.

Residence — Enter the addresses of the applicant's siblings or dependents (e.g., family home, out of town, or out of state).

D. Background Information

1. Educational Status — Enter the name of the school(s) (elementary school, middle school, high school or other college/technical school) the applicant is currently attending, if applicable.

2. Physician Information

Name of Primary Care Physician (PCP) or Other Physician Who Knows the Applicant — Enter the name of the applicant's primary care physician or other physician who knows the applicant.

Specialty — Enter the physician's specialty.

Date of Last Consultation — Enter the last date the applicant was seen by primary care physician/other physician.

Area Code and Telephone No. — Enter the area code and telephone number of the applicant's primary care physician/other physician.

Address (Physical Address of Office or Clinic) — Enter the physical address of the applicant's primary care physician/other physician.

3. Current Work/Employment Information of the Applicant

Name of Company or Business (if applicable) — Enter the name of the company/business where the applicant is employed, if applicable.

Company or Business Area Code and Telephone No. — Enter the area code and telephone number of the company/business where the applicant is employed, if applicable.

Company/Business Contact Person — Enter the name of the contact person of the company/business where the applicant is employed, if applicable.

Company/Business Address (if applicable) — Enter the address of the company/business where the applicant is employed, if applicable.

E. Services(s) Applicant is Currently Receiving (list all)

List all non-CLASS services the individual is currently receiving.

Name of Agency — Enter the names of all agencies currently delivering service to the applicant (e.g., Texas Health and Human Services Commission, Texas Department of State Health Services, Texas Health Steps, etc.).

Agency Area Code and Telephone No. — Enter the area code and telephone number(s) of all agencies currently delivering service(s) to the applicant, including area code.

Contact Person — Enter the name of the contact person of all agencies currently delivering service(s) to the applicant.

Address (City, State, ZIP Code) — Enter the address(es) of all agencies currently delivering service(s) to the applicant including city, state and ZIP code.

List of Services — List all services the applicant is receiving from the agency listed above.

F. Functional Status

If available, enter the name of the ABL instrument (ICAP, SIB-R, Vineland or AAIDD) used to assess the applicant's/participant's adaptive behavior level:

  • Vineland;
  • Inventory for Client and Agency Planning (ICAP)/Other;
  • Vineland ABL Standard Score;
  • Vineland Adaptive Behavior Scales, Second Edition (Vineland-II);
  • Scales of Independent Behavior — Revised (SIB-R); and
  • American Association of Intellectual and Developmental Disabilities (AAIDD) Adaptive Behavior Scales (ABS).

Language — Enter the primary language of the applicant/applicant's family.

Mobility — Enter any difficulties the applicant may have in the area of mobility.

Self-Care — Enter any difficulties the applicant may have in the area of self-care.

Strengths — Enter the applicant's strengths.

Targeted Behaviors — Identify any significant behaviors that are being targeted and addressed through a treatment plan and describe how those behaviors are being addressed. Provide the frequency of these behaviors. (This includes any significant behavior, including but not limited to, behavior that causes a threat to the applicant or others, such as engaging in illegal activities, disruptive behavior, aggressive behavior, sexually aggressive behavior or other.)

Non-targeted Behavioral Characteristics — Enter any non-targeted behavioral characteristics displayed by the applicant and identified by the applicant/LAR. Provide the frequency of these behaviors.

Consequences — Enter the consequences, if any, to the applicant when targeted or non-targeted behavior occurs.

G. Financial Information

Trust Funds — Enter any trust funds available to the applicant for non-waiver purposes.

Income the applicant currently receives — Enter any income the applicant is currently receiving, including, but not limited to employment, Social Security Income (SSI), Social Security Disability Income (SSDI), child support, etc. Enter the totals in the appropriate box(es).

Any other income not listed above (source and amount) — List any other income the individual receives that is not already listed in this section.

H. Inventory of Services Needed

Check the appropriate box(es) to indicate services requested.
List any additional services requested that are not provided in this list.
Transition Assistance Services (TAS) — Indicate if the individual needs assistance with Transition Assistance Services (TAS). Note: Money Follows the Person is not required for TAS.

Inventory of Community First Choice (CFC) Services Needed — Check the appropriate box(es) to indicate services requested.

I. Current Inventory of Adaptive Aids/Minor Home Modifications/Medical Supplies in Use

Check the appropriate box to indicate any adaptive aids or minor home modifications currently in use by the applicant.

List any additional adaptive aids or minor home modifications the individual receives or has received that are not included in this list.

J. Case History

Provide any information regarding the applicant's current or previous involvement in other program(s), medical history, family/non-waiver involvement. Provide information not previously identified in the additional case history section.

K. Applicant/LAR Rights to Information/Signature/Date

Signature/Date — The applicant/LAR reviews, signs and dates Form 3657 and acknowledges that they are entitled to receive and review the information and have the right to ask HHSC to correct information that is determined to be incorrect.

Case Manager Signature/Date — The case manager signs and dates this form to attest that this information is true and correct as presented by the applicant/LAR.