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?

YesNo
Is the Service Delivery Plan (SDP) 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
If Participant is over 18 years of age, is the participant their own representative on the plan? (YES if over age 18 & able to ‘direct own care’, signs off on their own plan documents, will approve staff timesheets, etc. This information is listed on the first page of the SDP under ‘Participant Representative).*

YesNo
Address*

Street Address / Unit / Apt

Street Address Line 2

CityState

Zip Code
County*
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

Only complete this section if the participant is not their own plan or legal representative.If the participant is their own representative, enter N/A in the name field.
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
Consultation Services Provider Agency
Consultation Services Coordinator Name

First NameLast Name
Waiver case manager / care coordinator name (if applicable)
Case Manager Phone
Please enter a valid phone number.
Case Manager Email
example@example.com
Consultations Services Email Address
example@example.com
How many personal care staff do you plan to onboard?
Please provide their contact information below.

If there is information you don’t know, no problem! You may still submit this referral. As long as you include the staff member’s phone number or email, we can gather the rest.

Applicant information will only be used to prefill the application and will be kept secure and confidential.
APPLICANT 1
Full legal name, including all middle and last names or hyphenated names (if applicable).

First NameMiddle 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.
APPLICANT 2
Full legal name, including all middle and last names or hyphenated names (if applicable).

First NameMiddle 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.
A quick review before submitting helps us move things forward as quickly as possible. Please ensure all information is complete and accurate.

One of our service coordinators will contact you shortly to schedule your intake meeting. Thank you!
Should be Empty:

Participant Information:

Participant Representative

Team Information