(To Be Completed by the Case Manager and Signed by Participant Or Guardian) Review

Emergency

Eligibility

(To be completed by the Case Manager and signed by Participant or guardian) Review

SIS

Comprehensive Supports Waiver ABI Waiver

Print Applicant/Participant Legal Name (Last, First, middle initial):______

Preferred name:______

SSN:______Birthdatemm/dd/yyyy:______Age:_____

Residential Address:______County: ______

Residential Phone: ______

Residential Placement (family, group/host home, SFHH, own home/apt, BOCES, etc.): ______

School/Day Program (none, preschool, school, day hab, community employment, etc.): ______

Case Manager:______Agency: ______Phone: ______

Legal Guardian Name: ______ Phone: ______

Legal Guardian Address: ______

Legal Guardian is: Self Parent DFS Rep. Non-Relative

Include all applicable documentation listed below with checklist for ICAPs only

(Send only the minimum information necessary to support eligibility)

Psychological Report ABI Waiver requires a neuropsychological report. Report must be within the last five years, shall be made by a licensed psychologist, and include the full-scale IQ andprimary diagnosis of the person.

Psychiatric Report (If available)

Documentation currently available on medical issues–Medical evaluation reports and/or letter from physicians to support diagnosis of a seizure disorder, ADHD, cerebral palsy, any genetic disorder, any neurological or neuromuscular disorder, or any condition which will be claimed as a medical problem requiring treatment by a nurse or physician

Positive Behavior Support Plan (If one is in place)

IPCpages: Demographicsand Medical Information (If an existing DDD funded participant)

List of Current Medications

Interdisciplinary Team Evaluation Report (Children only)

Incident Report summary, program data summary, parent notes (Any information or documentation to help substantiate problem behavior concerns within the last 3 months.)

List two (2) respondents and one (1) alternate(ICAP Respondents must have had contact with the applicant for the past three (3) months. Make a note if all three respondents should be interviewed.)The SIS is completed in a meeting with the Participant and his/her plan team. Please list the main contacts for the person’s team:

Name: ______Relationship: ______Phone #s(home/cell/or work): ______

**I hereby agree to have the assessment completed and authorize the above-named individuals to meet with evaluators from UW/WIND in confidential interviews to complete the ICAP assessmentand/ or SIS Assessment.

______

Applicant, Participant, or Guardian signatureDate of Signature

Behavioral Health Division ICAP / SIS Checklist Rev. 3/2016