CFSS Budget Model

Welcome - we're so glad you're here! This intake form is the first step in getting your FMS services set up smoothly. By collecting key details now, we can begin creating your file, start required paperwork, and coordinate with your team.All information you provide will remain secure and confidential, and only used to complete your enrollment.
CFSS
Is the Client transferring from a different FMS provider or previously participated in the CFSS Budget Model Program?

YesNoUnsure
Estimated start date of service

MonthDayYear
Date
Is the Service Delivery Plan (SDP) completed and/or approved?

YesNo
Participant Information:

Please enter all of the required information for the participant (the client, person served)
Participant Name*

First NameLast Name
Participant Date of Birth*

MonthDayYear
Date
If Participant is over 18 years of age, is there someone who has legal authority to make decisions for the participant (such as a legal guardian or Power of Attorney)?

YesNo
Address

Street Address / Unit / Apt

Street Address Line 2

CityState / Province

Postal / Zip Code
Participant Medical Assistance/PMI Number
Does the Participant currently utilize services with Life Fountain or utilized services in the past?

YesNo
Does the Participant have any immediate family who currently has services with Life Fountain?

YesNo
If Applicable, does the Participant have a spenddown?

YesNo
Participant Representative
Name of Participant Representative*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Relationship to Participant*
Communication Preference? (select all that apply)

EmailPhone
Address (if different from participant)
Does PR need an interpreter? If so, what language?
Team Information
County Case Manager Name
Case Manager Phone
Please enter a valid phone number.
Case Manager Email
example@example.com
Consultation Services Provider Agency
Consultation Services Coordinator Name

First NameLast Name
Consultations Services Email Address
example@example.com
How many staff applications are needed for employees?
By sharing some basic details up front, our team can prefill most of the paperwork for them. We strive to make process as smooth and easy as possible for your applicants/employees.

Applicant information will only be used to prefill the application and will be kept secure and confidential.
Name of Applicant - 1

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence
Email
example@example.com
Phone Number
Please enter a valid phone number.
Name of Applicant - 2

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence
Email
example@example.com
Phone Number
Please enter a valid phone number.
Should be Empty:

Participant Information:

Participant Representative

Team Information