Eligibilty Packet

Eligibility Packet
Dear Prospective Family Support participant,

We need information regarding your disablity to determine eligibility and/or redetermination of eligibility for Family Support Services. If you already have medical documentation that describes your disability, please send copies for eligibility review.

You may also choose to obtain the appropriate medical documentation from your physician or specialist without our assistance or need for the enclosed Release of Information. If you do not have this information, you may choose to complete and sign the enclosed Release of Information and we will reqeust documentation from your designated physician/specialist.

THIS RELEASE IS NOT REQUIRED AND YOU DO NOT HAVE THE RIGHT TO DECLINE

Family Support Office

The Arc Davidson County & Greater Nashville
Dear Prospective Family Support Participant,

As part of our ongoing efforts to ensure compliance with the State Guidelines for Family Support, we need to determine if you are eligible for the Family Support program. Once this form is thoroughly completed and returned to the Family Support office, a questionnaire will be sent to the listed physician for completion.

This statement is to serve as both notfiications and Relese of Information (ROI) to send to your physician along with a questionnaire regarding your disability/disabilities/ The questions will be based on the seven criteria that were used to determine initial eligibility.
Prospective Family Support Participant Name:

First NameLast Name
DOB

MonthDayYear
Date
Physician Name
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician Contact Office Phone Number
Please enter a valid phone number.
Fax
Please enter a valid phone number.
I,

First NameLast Name
authorize the above named physican to complete and return the Family Support Eligibility Questionanaire. I understand that this review will be used to determine my eligibility for Family Support Services
Signature of Program Participant of Legal Representative

Clear
Date

MonthDayYear
Date
Printed Name
Relationship to Prospective Program Participant
Family Support Intake Form

This is not an application for service and does not guarantee approval.

THIS FORM MUST BE FILLED OUT IN ITS ENTIRETY
Date

MonthDayYear
Date
County of Residence
Name of Person with severe/developmental disability applying for Family Support:
Social Security
Date of Birth

MonthDayYear
Date
Name of Parent/Spouse/Legal Representative if different than above
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Phone Number 2
Please enter a valid phone number.
Potential Support Services Needed/Requested(Check all that apply):

Before/After CareBehavior ServicesDaycareEmergency Living ExpensesFamily CounselingHealth RelatedHomemaker ServicesHome ModificationsNursing/Nurse's AidesPersonal AssitanceRecreation/Summer CampRespiteSpecialized Equipment & Maintenace RepairSpecialized Nutrition/Clothing SuppliesTrainingTransportationVehicle ModificationsOther
Do you (the person applying for Family Support) receive any of the following? (check all that apply):

Adoption AssistanceFood StampsResidential ServicesSocial Security IncomeSocial Security Disability IncomeFoster CareTennessee Early Intervention SystemPACE (Program of All-Inclusive Care for the ElderlyOPTIONS ProgramVocational RehabilitationNursing ServicesSupported LivingNone
What type of insurance do you (the person applying for Family Support) have?

TennCare (Medicaid)MedicarePrivate InsuranceUninsured
Have you (the person applying for Family Support) applied for or do you receive any of the following? (Check all that apply):

ChoicesECF ChoicesDIDD WaiversTBI GrantKatie Beckett ProgramAny in home or community supportsNone
To comply with Title VI, the following information is requesed:

MaleFemaleAfrican AmericanAsianCaucasianHispanicOtherUnknown
Primary Disability - Check with of the major disability categories is most relevant to the person with a severe dsaiblity as a primary disagnosis:

AutismCebral PalsyBlindDeafHealth ImpairmentTraumatic Brain InjryIntellectual DisabilityNeurological ImpairmentOrthopedic Impairment/Physical DisabilitySpinal Cord InjuryDevelopmental Delay (Birth - 8 yoDown SyndromeGenetic Disorders (ex. Rett, Angelman, Trisomy 9, etc.)Other
Did the persons primary disability occur:

Prior to age 22At age 22 or older
Notes: Please explain in detail how the Family Support funds would assist your family. Based on the diagnosis of the applicant, what needs is he/she unable to obtain without the supports? How would the applicant's daily life be improved with his assistance?
By signing and dating this Intake Form I, the person applying or their legal representative, indicate that all the information above is true and accurate. Furthermore, I understand that providing invalid, inaccurate, or incomplete information could be considered as fraud and may result in a criminal investigation and disqualification from the program which would prevent re-application in subsequent years.
Signature of Person Applying or Legal Representative

Clear
Date

MonthDayYear
Date
How was this information obtained (ie. face to face visit, by phone or mail)?
If someone other than the family/applicant is making a referral:
Name of Person making referral to Family Support
Agency
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Functional Limitations Assessment

This form needs to be complete3d by or for the person with the disability. All questions msust be answered. Must check all boxes that apply.

1. Self-Care: Refers to the daily personal skills required to maintain a healthy lifestyle. Check all that apply.
Do you need assistance with the following?

Oral HygieneBathingDressingEatingGroomingToiletingDoes not apply
2. Self-Direction: Refers to an individual's ability to make safe, wise decisions independently. Check all that apply.
Do you need someone to assist with your personal care, social or medical servics?

YesNo
Do you require assistance and struggle with making safe, wise decisions?

YesNo
Do you have difficulty understanding danger?

YesNo
Does not apply to anything in number 2

Does not apply
3. Receptive and Expressive Language: Refers to individual's ability to understand what others are saying and to communicate his or her own thoughts
Which options apply

Receptive Language: Struggles with understanding verbal questions or instructions from othersExpressive Language: You have difficulty communicating with othersDoes not apply
4. Learning: Refers to individuals ability to learn without additional supports and services. Check all that apply:
Do you have trouble performing age-appropriate tasks? (ie learning how to play a game or solve a math problem?

YesNo
Do you receive IEP services

YesNo
Do you have problems with memory and reasoning?

YesNo
Do you need occasional reminders to complete routine tasks and recall past events?

YesNo
Does not apply to Number 4

Does not apply
5. Mobility: Refers to the ability to move around and use his or her physical abilities in the environment. Check all that apply
Do you have difficulty getting around the house, going up and down stairs, going to the mailbox,,etc?

YesNo
Do you use specialized equipment needed for mobility I.e. cane, walker, wheelchair?

Yesno
Do you require specialized equipment and/or transportation to leave the house?

YesNo
Does not apply to number 5

Does not apply
6. Capacity for indepedent living: Refers to an ability to engage in the activities needed for everyday life. Check all that apply.
Do you depend on a family member/caregiver to perform all your housework?

YesNo
Do you depend on a family member/caregiver to prepare your meals?

YesNo
Do you depend on a family member/caregiver to run your community errands?

YesNo
Are you able to manage your money?

YesNo
Do you use medical equipment at home that is powered by electricity?

YesNo
Does not apply to number 6

Type option 1
7. Economic Self-Sufficiency: Refers to the ability to obtain and retain a job in a competitive work environment
Are you of school age?

YesNo
Are you an adult who is unable to work due to their disability?

YesNo
Have you had difficulty retaining a job due to your disability?

YesNo
How would the program benefit you?
How has your disability impacted your support systems (family, extended family, friends, and outside provider(s)??
Upload Proof of Disability

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Eligibility Packet

Family Support Intake Form