Medicaid Waiver Behavior Support Inquiry
Applied Behavioral Approaches
Provider Identification
Legal Name of Company/Provider
*
DBHDD Provider ID
DBA
Which funding source(s) support your program (Select all that apply.)?
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COMP Waiver
NOW Waiver
Other
Which best describes your program?
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Adult Day Services/Community Access
Supported Employment/Pre-Vocational
Community-Based Adult IDD Services
Residential Facility/Group Home
Other
Group Home Program Overview (Select one)
24-Hour Staffed Group Home
Supported Living / Host Home
Transitional Residential Program
Other
Group Home Staffing Structure (Select all that apply.)
Awake overnight staff
Sleeping overnight staff
Rotating shifts
Consistent staff assignments
Float / relief staff used
Other
Behavior Support Context (Select all that apply.)
BSPs currently in place
BSPs due for review or update
No restrictive interventions currently in use
Restrictive interventions currently authorized
Other
Primary Daily Activities (Select all that apply.)
On-site daily routines (meals, hygiene, leisure)
Community access activities
Attendance at adult day programs
Supported employment / vocational activities
Other
Behavioral Intensity Snapshot
Low: Infrequent, predictable behaviors that respond to routine supports; no safety concerns.
Moderate: Recurring behaviors that interfere with routines at times but are managed with a BSP and not a current crisis.
Histoy of Incidents: Past significant behavioral incidents; currently stable with supports in place and no active crisis.
Other
Program Overview
Primary Service Model
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Center-Based
Community-Based
Residential
Mixed
Consumer Profile
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Adults with intellectual disability
Adults with autism spectrum disorder
Adults with co-occurring mental health diagnoses
Adults with medical complexity
Other
Approximately how many adult participants are served under this request (Select one)?
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1 - 5
6 - 10
11 - 20
20 - 30
Other
How many sites does this request involve (Select one)?
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1 site
2 - 3 sites
4 - 5 sites
Other
City & County of Site 1
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Number of consumers at Site 1.
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City & County of Site 2
Number of consumers at Site 2.
City & County of Site 3
Number of consumers at Site 3.
City & County of Site 4
Number of consumers at Site 4.
City & County of Site 5
Number of consumers at Site 5.
Scope of Services
What prompted this request for behavior support? (Select all that apply.)
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New BSP development
BSP updates/revisions
Ongoing monitoring
Staff training tied to BSPs
Transition support
Compliance/documentation support
Other
Approximately how many behavior support hours do you need?
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4 - 8 hours/month
9 - 15 hours/month
16 - 20 hours/month
21 - 30 hours/month
Other
Consumers' Behavior Intensity
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Low behavioral intensity
Moderate behavioral intensity
History of behavioral incidents (not current crisis)
Other
Which service model would work for your program?
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Hybrid (telehealth + periodic in-person visits)
Primarily telehealth with scheduled site visits
Primarily in-person (scheduled only)
Other
Preferred Contract Structure
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Per site
Per individual
Unsure/open to recommendation
Other
Desired Start Date
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Immediately
Within 30 days
Within 60 days
Within 90 days
Other
Please confirm the following statements are true for your program:
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We are seeking scheduled Level 2 behavior support services.
We are not seeking crisis response or emergency services.
We do not require on-call or after-hours availability.
We are not seeking 24/7 or intensive stabilization services.
Other
Person Completing this Form
Name
*
First Name
Last Name
Title/Role
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Is there another individual who serves as the primary contact?
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Yes
No
Name and number of priamry contact
Please provide any additional information here.
Please verify that you are human
*
Submit
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