Language
English (US)
Español
The Arc.
Davidson County
& Greater Nashville
For people with intellectual and developmental disabilities
Achieve With Us.
Dear Prospective Family Support participant,
We need information regarding your disability to determine 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 form and we will request documentation from your designated physician/specialist.
THIS RELEASE IS NOT REQUIRED AND YOU DO HAVE THE RIGHT TO DECLINE
Family Support Office
The Arc Davidson County & Greater Nashville
545 Mainstream Drive • Suite 110 • Nashville, TN 37228
Phone: 615-321-5699 / Fax: 615-322-9184
www.arcdc.org/familysupport
Back
Next
Save
The Arc.
Davidson County
& Greater Nashville
For people with intellectual and developmental disabilities
Achieve With Us.
Dear Prospective Family Support Participant,
As part of our ongoing efforts to ensure compliance with 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 notification and Release 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:
DOB:
-
Month
-
Day
Year
Date
Physician Name:
Physician Address:
Physician Contact Numbers: Office:
Format: (000) 000-0000.
Fax:
Format: (000) 000-0000.
Physician Email:
example@example.com
******YOU MUST INCLUDE YOUR PHYSICIAN'S FAX NUMBER OR EMAIL.
ROI SHEETS WITHOUT THE FAX NUMBER OR EMAIL WILL NOT BE ACCEPTED*****
I, ____________________________________ (Prospective Family Support Participant), authorize the above named physician to complete and return the Family Support Eligibility Questionnaire. I understand that this review will be used to determine my eligibility for Family Support Services.
Signature of Prospective Program Participant or Legal Representative:
Date:
-
Month
-
Day
Year
Date
Printed Name:
Relationship to Prospective Program Participant:
545 Mainstream Drive, Suite 110, Nashville, TN 37228
Phone: 615-321-5699 / Fax: 615-322-9184
www.arcdc.org/familysupport
Back
Next
Save
Family Support Intake Form
Name of person with severe/developmental disability that Family Support is being applied for:
Social Security #
Date of Birth
-
Month
-
Day
Year
Date
Age:
Name of Parent/ Spouse / Legal representative, if different than above,
Family's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
Format: (000) 000-0000.
Phone
Format: (000) 000-0000.
County
Email Address
example@example.com
Potential Support Services Needed/Requested (Check services needed):
Before/After Care
Home Modifications
Specialized Equip & Repair/Maintenance
Recreation/Summer Camp
Behavior Services
Home Maker Services
Specialized Nutrition/Cloth/ Supplies
Vehicle Modifications
Day Care
Nursing/Nurses Aide
Training
Other: Conservatorship/ Special Needs Trust
Emergency Living Expenses
Personal Assistance
Transportation
Family Counseling
Respite
Health Related
Do you (the person applying for Family Support) receive any of the following? (Check all that apply)
Adoption Assistance
Social Security Income
Tenn. Early Intervention System (TEIS)
Vocational Rehabilitation
Food Stamps
Social Security Disability Income
PACE (Program of All-Inclusive Care for the Elderly)
Nursing Services
Residential Services
Foster Care
MAPs (Medicaid Alternative Pathway to Independence)
Supported Living
OPTIONS Program
None
What type of insurance do you (the person applying for Family Support) have?
TennCare (Medicaid)
Medicare
Private Insurance
Uninsured
Have you (the person applying for the Family Support) applied for or do you receive any of the following? (Check all that apply)
CHOICES
ECF CHOICES
DDA Waiver
Katie Beckett Program
Any in home or community supports
None
Back
Next
Save
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")
RACE
American
African American/Black
Caucasian/White
Hawaiian/Other Pacific Islander
Asian
Other
Caucasian/White
2. ETHNICITY (if self-identified as "Hispanic/Latino, "please answer the Race question separately above and then "Hispanic/Latino" here
ETHNICITY
Hispanic/ Latino
Non- 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):
Primary Disability
Autism
Cerebral Palsy
Blind
Deaf
Health Impairment
Traumatic Brain Injury
Other
Intellectual Disability
Neurological Impairment
Orthopedic Impairment/ Physical Disability
Spinal Cord Injury
Developmental Delay (Birth - 8 y.o.)
Down Syndrome
Genetic Disorders: (ex. Rett, Angelman, Trisomy 9, etc) Please specify:
Please specify:
Did the person's primary disability occur:
Did the person's primary disability occur:
Prior to age 22
At age 22 or after
Is the person with the disability a US Citizen?
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 applicant's daily life be improved with this assistance? Use additional paper if necessary.
Explanation
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
Date
-
Month
-
Day
Year
Date
If someone other than the family/applicant dual is making a referral:
Name of individual making referral to Family Support
Agency
Phone
Format: (000) 000-0000.
Address
Back
Next
Save
Functional Limitations Assessment
If you are unable to complete this form, please ask your caregiver and /or family member
Must check all applicable boxes
1. Self-Care: Refers to the daily personal skills required to maintain a healthy existence.
Do you need assistance with the following (check all that apply)
Oral hygiene
Dressing
Grooming
Bathing
Eating
Toileting
Not applicable
2. Self-direction: Refers to an individual's ability to make safe, wise decisions independently.
Do you need assistance with the following (check all that apply)
Do you need someone to coordinate your personal care, social or medical services?
Do you require assistance and struggle with making safe, wise decisions?
Do you have difficulty in comprehending danger?
Not applicable
3. Receptive and Expressive Language: Refers to individual's ability to understand what others are saying and to communicate his or her own thoughts
Receptive Language: Struggles with understanding verbal questions or instructions from others
Expressive Language: You have difficulty communicating with others
Not applicable
4. Learning: Refers to individual's ability to learn without additional supports and services
Do you have trouble performing age-appropriate tasks? (I.e. learning how to play a game or solve a math problem)?
Do you receive IEP services?
Do you have problems with memory and reasoning?
Do you need occasional reminders to complete routine tasks and recall past events?
Not applicable
TURN OVER
Back
Next
Save
5. Mobility: Refers to the ability to move around and use his or her physical abilities in the environment
Do you have difficulty getting around the house, going up and down stairs, going to the mailbox....?
Do you use specialized equipment needed for mobility i.e. cane, walker, wheelchair?
Do you require specialized equipment and /or transportation to leave the house?
Not applicable
6. Capacity for Independent Living: Refers to an ability to engage in the activities needed to live and work
Do you depend on a caregiver to perform all your housework?
Do you depend on a caregiver to prepare your meals?
Do you depend on a caregiver to run your community errands?
Are you able to manage your money?
Not applicable
Do you use medical equipment at home that is powered by electricity?
7. Economic Self-Sufficiency: Refers to the ability to obtain and retain a job in a competitive work environment
Are you of school age?
Are you an adult who is unable to work due to their disability?
Have you had difficulty retaining a job due to your disability?
How has the program benefited you? If you are on the waitlist how would the program benefit you?
How has your disability impacted your support systems (family, extended family, friends, and outside providers)?
Proof of Disability- Documentation must state that the disability is lifelong/permanent.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Preview PDF
Save
Submit
Should be Empty: