2025-2026 English Re-Eligibility

Department of Disability & Aging
Name of person with severedevelopmental disability that Family Support is being applied for
Social Security
Date of Birth

MonthDayYear
Date
Age
Name of Parent Spouse Legal representative if different than above
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County
Phone
Phone
Email Address
example@example.com
Potential Support Services Needed/Requested (Check services needed):

Before/After CareBehavior ServicesDay CareEmergency Living ExpensesFamily CounselingHome ModificationsHome Maker ServicesNursing/Nurses AidePersonal AssistanceRespiteSpecialized Equip & Repair/MaintenanceSpecialized Nutrition/Cloth/SuppliesTrainingTransportationHealth RelatedRecreation/Summer CampVehicle 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 CareOPTIONS ProgramTenn. Early Intervention System(TEIS)PACE (Program of All-Inclsuive Care for the Elderly)MAPS (Medicaid Alternative Pathway to Independence)Vocation 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 the Family Support) applied for or do you receive any of the following? (Check all that apply)

CHOICESECF CHOICESDDA WAIVERKatie Beckett ProgramAny in home or community supportsNone
To comply with Title VI, the following information is requested: 1. RACE (Check all that apply) (federal standards consider "Hispanic/Latino to be an Ethnicity, to be answered below, separate from "Race")

American Indian/Alaskan NativerAfrican American/BlackCaucasian/WhiteAsianHawaiian/Other Pacific IslanderOther
2. ETHNICITY (if self-identified as "Hispanic/Latino, "please answer the Race question separately above and then "Hispanic/Latino" here

Hispanic/LatinoNon-Hispanic/Latino
Primary Disability - Check which of the following "major disability categories" is most relevant to person services are being requested for (as a primary diagnosis):

AutismCerebral PalsyBlindDeafHealth ImpairmentTraumatic Brain InjuryIntellectual DisabilityNeurological ImpairmentOrthopedic Impairment/Physical DisabilitySpinal Cord InjuryDevelopmental Delay (Birth - 8yo)Down SyndromeOtherGenetic Disorders: (ex. Rett, Anglman, Trisomy 9, etc.) Please specify
Did the person's primary disability occur:

Prior to age 22At age 22 or after
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 dash she unable to obtain without these supports How would the applicants daily life be improved with this assistance Use additional paper if necessary
By signing and dating this intake form, I, the person applying or the 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 criminal investigation and disqualification from the program which would prevent reapplication in subsequent years.
Signature of Person Supported or Legal Representative

Clear
Date

MonthDayYear
Date
If someone other than the family/applicant dual is making a referral:
Name of individual making referral to Family Support
Agency
Phone
Address
Functional Limitations Assessment

This form is to assess the person with the disability. All questions must be answered. Check all boxes that apply.
1. Self-Care: Refers to the daily personal skills required to maintain a healthy lifestyle. Check all that apply.
Oral Care

YesNoAbility remains the same
Bathing

YesNoAbility remains the same
Dressing

YesNoAbility remains the same
Feeding yourself

YesNoAbility reamains the same
Grooming

YesNoAbility remains the same
Toileting

YesNoAbility remains the same
2. Self-direction: Refers to an individual's ability to make safe, wise decisions independently. Check all that apply.
I need someone to assist with my personal care, social or medical services

YesNoAbility remains the same
I am unable to make safe, wise decisions and have difficulty understanding danger.

YesNoAbility remains the same
3. Receptive and Expressive Language: Refers to an individual's ability to understand what others are saying and to communicate his or her own thoughts.
Verbal

YesNo
Non-Verbal

YesNo
I struggle with understanding verbal questions or instructions from others. I have difficulty communicating with others.

YesNoAbility remains the same
I have difficulty communicating with others.

YesNoAbility remains the same
4. Learning: Refers to an individual's ability to learn without additional supports and services. Check all that apply.
I have trouble performing age-appropriate tasks.

YesNoAbility remains the same
I receive IEP services

YesNoAbility remains the same
5. Mobility: Refers to the ability to move around and use his or her physical abilities in the environment. Check all that apply.
I have difficulty getting around the house, going up and down stairs, and/or going to the mailbox.

YesNoAbility remains the same
I require specialized equipment needed for mobility i.e. cane, walker, wheelchair.

YesNoAbility remains the same
I require specialized transportation to leave home such as WeGo or ride share.

YesNoAbility remains the same
6. Capacity for Independent Living: Refers to an ability to engage in the activities needed for everyday life. Check all that apply.
I depend on a family member / caregiver to perform all housework

YesNoAbility remains the same
I depend on a family member / caregiver to prepare my meals

YesNoAbility remains the same
I depend on a family member / caregiver to run my community errands

YesNoAbility remains the same
I am able to manage my money

YesNoAbility remains the same
Do you use medical equipment at home that is powered by electricity?

YesNo
If yes what medical equipment do you use daily
7. Economic Self- Sufficiency: Refers to the ability to obtain and retain a job in a competitive work environment.
I am of school age

YesNoAbility remains the same
I am an adult who is unable to work due to my disability

YesNoAbility remains the same
I am an adult who has difficulty retaining a job due to my disability

YesNoAbility remains the same
REQUIRED
How will the program continue to benefit you
REQUIRED
How has your disability impacted your support systems family extended family friends and outside providers
Should be Empty:

Functional Limitations Assessment

REQUIRED

REQUIRED