Support Coordination Case Summary
Request for Intensive Case Management
(Please complete and return to your assigned Mentor)
Reason for Referral: Choose an item.Out of Home SupportsIn-Home SupportsCase Consultation / Date:
Name of Individual: / Date of Birth:
DDD ID: / County:
Address: / Phone Number:
Name of Guardian: / Phone Number:
DDRT Score: / Medicaid Eligible: Choose an item.YesNo
SUPPORT COORDINATION INFORMATION
Name of Support Coordination Agency:
Name of Support Coordinator:
Phone Number: Email:
Name of Support Coordinator Supervisor:
Phone Number: Email:
Name of Division Mentor:
Phone Number: Email:
CURRENT SERVICES
Day Program/Employer: Schedule:
Mental Health Services: Frequency:
Medicaid Services: Frequency:
Family Support Services: Frequency:
Natural Supports: Frequency:
Other Services: Frequency:
Are there any services that are pending? Choose an item.YesNo
If yes, please describe:
IMPORTANT INFORMATION
What prompted the request for Intensive Case Management?
What is date of the last home visit and what were the details?
Is there anything unique to the individual or family that would be helpful as the Division begins to link them to the most appropriate services and supports? Choose an item.YesNo
If yes, please describe:
Are there any barriers that would limit the individual from obtaining their requested services and supports? Choose an item.YesNo
If yes, please describe:
Is there any information related to religious or cultural preferences that would be important for the Division to be aware of in order to provide Intensive Case Management? Choose an item.YesNo
If yes, please describe:
Has Adult Protective Services been involved with this individual or family? Choose an item.YesNo
If yes, please describe:
Has any Unusual Incident Reports been completed? Choose an item.YesNo
If yes, please describe:
Provide an overall assessment of the current situation and service needs, including services offered:
HISTORY OF HOSPITALIZATIONS
Reason(s) for Hospitalization: Choose an item.Behavioral/Mental HealthMedical
Date of Hospitalization(s):
Has the Clinical Team been involved in the past? Choose an item.YesNo
ATTACHED DOCUMENTS
Current Plan of Care (ISP/ELP)
PCPT
DDRT
Letter from Family requesting emergency placement
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