Milwaukee County’sComprehensive Community Services (CCS)

Program Description and Application Form

General Description:

The Comprehensive Community Services (CCS) program is a community-based psychosocial rehabilitation service that provides or arranges for medical and remedial services and supportive activities that can assist a participant in achieving his or her highest possible level of independent functioning, stability, and to facilitate recovery. This program may be an attractive alternative to Community Support Program or Targeted Case Management services.

Who is Eligible?

The program is an entitlement for individuals receiving MedicalAssistance (T-19). A consumer could be a person of any age with either a mental disorder or a substance use disorder (or both), AND be in need of on-going, comprehensive services to minimize the effects of their disorder (s) and maximize independent functioning.

Program Components:

The consumer will identify members of their Recovery Team. The Recovery Team will consist of professionals and individuals from the consumer’s natural support system. The team will utilize the expertise of all members, including the consumer, to determine psychosocial supports and services required to assist the consumer in meeting their self-identified goals moving them forward in their journey of recovery.

Participants in CCS continue to utilize their Medical Assistance (T-19) card for most purposes. Through CCS, Milwaukee County is able to develop a network of unique and innovative psychosocial rehabilitation services in accordance with an individual’s needs.

Recovery Principles:

Services are provided in a manner that is respectful, culturally sensitive,collaborative,based on consumer choice, and protective of consumer rights.

PROGRAM APPLICATION

Please complete the information below and either bring or send the completed application to: 9201 W. Watertown Plank Road, Milwaukee, WI 53226. Fax Number: (414)454-4242. If you currently receive services from an existing Clinical Services program, please ask your assigned worker to forward this to Milwaukee County’s CCS Program.

Milwaukee County’s

Comprehensive Community Services (CCS)

Application (or referral) for Services

Name:Click here to enter text. Date of Application:Click here to enter text.

Date of Birth:Click here to enter text. Gender:☐Female ☐Male

Address: City:Click here to enter text.

Zip:Click here to enter text.

Home Phone:Click here to enter text. Other Phone:Click here to enter text.

Referral Source: ☐Self ☐MH/AODA Outpatient Service Provider ☐Hospital

☐Crisis Services ☐Medical Provider ☐Other Click here to enter text.

If you are making this referral on behalf of an individual, please provide your contact information below:

CONTACT NAME / ADDRESS / PHONE NUMBER / RELATIONSHIP TO INDIVIDUAL
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /

Insurance: ☐Yes Type/Policy Number: Click here to enter text.

☐No Insurance

Reason for application:Click here to enter text.

Do you currently receive services fromany Milwaukee County Community Access to Recovery Services (CARS) service provider? (casemanagement, therapy, representative payee, psychiatry, nursing, adult family home services, etc.)

□ Yes □ No

If you checked Yes,please list the provider(s) and address(es) below:

PROVIDER / ADDRESS
Click here to enter text. / Click here to enter text. /
Click here to enter text. / Click here to enter text. /
Click here to enter text. / Click here to enter text. /
Click here to enter text. / Click here to enter text. /

Do you currently receive services from any other service provider? (case management, therapy, representative payee, psychiatry, nursing, adult family home services, etc.)

☐Yes ☐No

If you checked Yes,please list the provider(s) and address(es) below:

PROVIDER / ADDRESS
Click here to enter text. / Click here to enter text. /
Click here to enter text. / Click here to enter text. /
Click here to enter text. / Click here to enter text. /
Click here to enter text. / Click here to enter text. /

Do you have a legal guardian?

☐Yes ☐No

If you checked Yes,please provide your guardian’s information below:

GUARDIAN / ADDRESS / PHONE NUMBER
Click here to enter text. / Click here to enter text. / Click here to enter text. /

Do you have a CCS agency preference? ☐Yes ☐No

If yes, please list the agency: Click here to enter text.

Reason for referral:Click here to enter text.