Family Support Intake Form
THIS FORM MUST BE FILLED OUT IN ITS ENTIRETY
Today's Date:
*
County of Residence:
*
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 Legal Representative, if different than above:
*
If you are applying for yourself, put n/a. If you have conservatorship or Power of Attorney, you will need to provide that documentation.
Address:
*
E-mail:
example@example.com
Phone:
*
Format: (000) 000-0000.
Potential Support Services Needed/Requested (Check all that apply, at least 3):
*
Before/After Care
Behavior Services
Day Care
Education/Home School/Tuition
Emergency Living Expenses
Family Counseling
Funeral/End of Life Expenses
Health Related
Home Modifications
Homemaker Services
Nursing/Nurse's Aid
Personal Assistance
Recreation/Summer Camp
Respite
Service Animals
Specialized Equipment & Maintenance/Repair
Special Needs Trust/Supported Decision Making/Power of Attorney/Conservatorship/ Guardianship
Specialized Nutrition/ Clothing/Supplies
Training
Transportation
Vehicle Modifications
Other
Do you (the person applying for Family Support) receive any of the following? (Check all that apply):
*
Adoption Assistance
Food Stamps
Residential Services
Social Security Income
Social Security Disability Income
Foster Care
OPTIONS Program
Tennessee Early Intervention System (TEIS)
PACE (Program of All- Inclusive Care for the Elderly)
MAPs (Medicaid Alternative Pathway to Independence)
Vocational Rehabilitation
Nursing Services
Supported Living
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 Family Support) applied for or do you receive any of the following? (Check all that apply):
*
CHOICES
ECF Choices
DDA Waivers
Katie Beckett Program
Any in home or community supports
Applied for one of the above, but are on the waitlist. (Please also choose the program you're waiting for.)
None
To comply with Title VI, the following information is requested:
1. RACE (Check all that apply)
*
American Indian/Alaskan Native
Asian
Black or African American
Hispanic or Latino
Middle Eastern or North African
Native Hawaiian or PacificIslander
White
Other (including 2 or more races)
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Family Support Intake Form, page 2
Primary Disability-Check which of the following "major disability categories" is most relevant to the person services are being requested for (as a primary diagnosis). If more than one diagnosis, enter them in the "other" category.
*
Autism
Cerebral Palsy
Blind
Deaf
Health Impairment
Traumatic Brain Injury
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.)
Other
Did the person's primary disability occur:
*
Prior to age 22
At 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/she unable to obtain without this support? How would the applicant's daily life be improved with this assistance? Use additional paper if necessary.
By signing and dating this Intake Form I, the person applying or their 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 a criminal investigation and disqualification from the program which would prevent re-application in subsequent years.
Signature of Person Applying or Legal Representative
*
Date
*
-
Month
-
Day
Year
Date
How was this information obtained (i.e., face-to-face visit, by phone or mail)?
*
If someone other than the family/applicant is making a referral:
Name of person making referral to Family Support:
Agency:
Phone:
Format: (000) 000-0000.
Address:
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