[Current Date]
[FIRST NAME] [LAST NAME]
[ADDRESS]
[CITY] [STATE] [ZIP]
Each year the Division of Services for People with Disabilities re-assesses the number of people waiting for Division services and the costs of services needed. This is necessary so that our records and cost estimates presented to the governor and legislature do not included people who have died or moved out of state. Our records indicate that you or your family member is waiting for funding from the Division. We need your assistance to complete our assessment. Please help us by completing the enclosed survey and mailing it back in the enclosed postage-paid envelope. Please return the survey by [August 21, Current Year]. Your reply is necessary to maintain a place on the waiting list.
If you do not return a completed survey by [August 21, Current Year], we will assume that you no longer require supports and will take your name or your family member’s name off the waiting list. We appreciate your response to the survey, even if you are no longer interested in receiving supports, so that we are certain you received the survey.
The survey should take five to ten minutes to fill out. Your responses will be kept confidential and used to update our information on the waiting list. Please refer to the enclosed “Service/Support Descriptions” document for information on support criteria. Before a person can be placed on the waiting list for a particular support, he or she must meet all support criteria. If you have additional questions, please call [Worker Name] at [Worker Number]. Your assigned Division worker may call you in the coming weeks to ask more specific questions about your needs or your family member’s needs.
Definitions for Waiting List terms:
Division means the Division of Services for People with Disabilities, the state agency that pays for supports.
Immediate Need means any support or service that you or your family member could use if it were available today. For example, as of today you or your family member needs support to live outside the family home, support during the day, or support to find or keep a job. (**Please note that an adult must be at least 21 years old before they can be placed on the immediate needs waiting list for day support or supported employment.)
Future Need means any support service that is not needed today but will be needed at some time in the future (**Please note that a child must be at least 16 years old before they can be placed on the future needs waiting list for day support or supported employment. There is no age limitation for individuals waiting for other supports.)
Waiting List means the database that stores the name, immediate support needs, priority, and demographical information of persons with disabilities seeking funding from the Division.
Sincerely,
Dr. George Kelner, Director
WAITING LIST SURVEY
[Current Year]
Region Office: [Region Office Code] Worker: [Worker Name]
HLCI Number: [HLCI Number] Phone: [Worker Phone]
1. Do you want to continue to wait for DSPD services (please circle one)? Y / N
**If you answered “No” to number 1, please STOP and return the survey in the enclosed self-addressed, stamped envelope. Your name will be removed from the waiting list and you will no longer be eligible to receive Division funding for supports or services.
2. PERSONAL INFORMATION. Column A (below) lists the information we have about you in our data system. Please review this information. If it is not correct, please make updates and changes in Column B.
COLUMN A (Current Info) / COLUMN B (Updates/Changes?)Name / [CONSUMER NAME]
Address / [CONSUMER ADDRESS]
[CITY] [STATE] [ZIP]
Phone / [CONSUMER PHONE]
Date of Birth / [CONSUMER DOB]
3. IMMEDIATE NEEDS. We currently have you on the waiting list for the following immediate needs (i.e. Division supports you need as of today).
Immediate Needs / Updates/Changes?[Immediate Service Need #1]
[Immediate Service Need #2] – etc.4. FUTURE NEEDS. We currently have you waiting for the following future needs (i.e. Division supports you will need in the future / several years).
Future Needs / Updates/Changes?[Future Service Need #1]
[Future Service Need #2] – etc.
[In rare cases, consumer may have 3-4 immediate and 3-4 future needs – need space here just in case – do not want # of needs to push this page into a new page]
Comments?______
______
Form Completed by (Name):______Phone Number:______
Relationship to Consumer:______
Address:______
WAITING LIST SERVICE/SUPPORT DESCRIPTIONS
Professional Parents is an out-of-home placement for children under the age of 18 to