Case Management Assessment Template – Fill Out and Use This PDF

The Case Management Assessment form serves as a comprehensive tool, designed to gather essential information about an individual in need of case management services. It includes sections on consumer information, demographics, legal decision-makers, emergency contacts, health status, and eligibility for Home- and Community-Based Services (HCBS) waivers, among others. Individuals and guardians are encouraged to thoroughly complete this form to ensure a tailored and effective case management plan. To begin the process, please click the button below.

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Case Management Assessment Template PDF Details

The Case Management Assessment Form is an essential document designed to gather comprehensive information about individuals in need of various social services, often within the context of Home- and Community-Based Services (HCBS). It encompasses a wide range of categories, ensuring that every facet of the consumer's life and needs is meticulously documented. The form captures basic consumer information such as name, address, Medicaid ID, and contact details, facilitating easy identification and communication. It also distinguishes between the types of assessment conducted, whether it's initial, annual, or due to a significant change in the consumer's demographic information or service needs. In an effort to tailor services accurately, the form delves into eligibility criteria based on a myriad of conditions and waivers, from intellectual disabilities to brain injuries, emphasizing the need for a personalized approach in case management. Crucial to the assessment is a section dedicated to verifying the consumer's choice between HCBS and medical institutional services, underscoring the principle of consumer autonomy in service selection. An interdisciplinary approach is encouraged, with records and consultations from various team members integrated into the assessment to ensure a holistic view of the consumer's situation. Legal decision-making capacities, financial management, emergency contacts, and detailed medical and mental health information are methodically recorded, providing a thorough backdrop for designing an effective case management plan. This tool's comprehensive nature makes it indispensable for case managers aiming to deliver customized, high-quality care and support to their consumers.

Question	Answer
Form Name	Case Management Assessment Template
Form Length	31 pages
Fillable?	Yes
Fillable fields	1644
Avg. time to fill out	37 min 24 sec
Other names	case management forms pdf, case management assessment template, case document forms, case management intake form

Form Preview Example

Case Management Comprehensive Assessment

Section A: Consumer Information

Consumer

Name: (First, M.I., Last)

Current Address:

Medicaid State ID#

Date Of Birth:

County of Residence:

Home Phone:

	County of Legal Settlement:

Work Phone:		Cell Phone:

E-mail:

Assessor

Name:

Title:

Agency:

Address:

Phone:

E-Mail:

Signature

Date

Type of Assessment
Initial
Annual
Special
Demographic Change Only				Date:
Discharge			Date:	Reason:
Basis of Case Management Eligibility
CMI	MR	DD	BI Waiver	Elderly Waiver

CMH Waiver

Habilitation

MFP

VERIFICATION OF HCBS WAIVER CONSUMER CHOICE: Complete this section for consumers applying for HCBS Brain Injury Waiver, Children’s Mental Health Waiver, Intellectual Disability Waiver.

Home- and Community-Based Services (HCBS)

My right to choose a Home- and Community-Based program has been explained to me. I have been advised that I may choose:

(1) Home- and Community-Based Services or (2) Medical Institutional Services.

I choose:	HCBS	Medical Institutional Services
Signature of Consumer or Guardian or Durable Power of Attorney for Health Care			Date

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:

Interdisciplinary team members consulted (including consumer):

Name

Title (if applicable)

Relationship to Consumer

Additional records reviewed:

Consumer Demographics

Gender:

Female

Male

Language:

Speaks English

Understands English

Needs interpreter services

Comments:

Yes

Monthly Income: (Please check all that apply)
Source	Amount
SSI	$
SSDI	$
Employment	$
Other (specify):	$
Comments:
Court Involvement:
Involuntary Commitment
Probation or Parole
Child in Need of Assistance (CINA)
Child Protection
Delinquency
Foster Care
Other (Identify)
None
Comments:

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:

Legal decision maker: (Please check all that apply)

None Guardian Attorney-in-fact Name: (First, M.I., Last)

Other (Specify):

Address:

Home Phone:

Work Phone:

Cell Phone:

E-mail:

Co-Decision Maker (if applicable):

Guardian Attorney-in-fact Name: (First, M.I., Last)

Other (Specify):

Address:

Home Phone:

Work Phone:

Cell Phone:

E-mail:

Financial Decision Maker: (e.g. Conservator or Attorney-in-fact)	No
Name: (First, M.I., Last)

Yes

(complete below)

Address:

Home Phone:			Work Phone:	Cell Phone:

E-mail:

Payee:	No	Yes (complete below)
Name: (First, M.I., Last)

Address:

Home Phone:			Work Phone:	Cell Phone:

E-mail:

Emergency Contacts:
Primary Contact
Name: (First, M.I., Last)				Relationship:

Address:

Home Phone:			Work Phone:	Cell Phone:

E-mail:

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:

Secondary Contact (if applicable):

Name: (First, M.I., Last)		Relationship:

Address:

Home Phone:	Work Phone:	Cell Phone:

E-mail:

Complete This Section For Adults (Age 18 and Over)

Veteran:

Yes

Marital Status:
Never Married
Married	Spouse’s Name:
Divorced

Legally Separated

Widowed

Unknown or Other – Specify

Comments:

Complete This Section For Children (Age 17 and Under)

With whom does the child live?

(If the child currently lives in a institutional setting, please make note in the comments section below.)

What are the child’s parent’s names?

Parents marital status:

Married

Divorced

Never married

If the parent’s are not living together, what is the non-custodial parent’s name and address? Name:

Street:

City, State, Zip:

Parent’s contact information (if different from the child’s):

Home Phone:

Work Phone:

Cell Phone:

E-Mail:

Are there siblings in the home?	Yes	No
Are any siblings receiving waiver services?		Yes	No

Are there any individuals who are not supposed to have contact with the child? If yes, specify:

Other Comments:

Yes

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:

Medical Information

Diagnoses:

Medical:

Diagnosis

Name and credential of professional making diagnosis:

Date of diagnosis:

Comments:

Mental Health (DSM-IV-TR)

Axis 1:

Axis 2:

Axis 3:

Axis 4:

Axis 5:

Name and credential of professional making diagnosis:	Date of diagnosis:

Comments:

Complete this section for consumers applying for or receiving HCBS Intellectual Disability Waiver.

List the most current IQ score, or if the IQ isn’t listed, give the consumer’s level of functioning within the range of mental retardation (mild, moderate, severe, profound):

IQ:

Range:

Date of Evaluation:

Complete this section for consumers applying for or receiving HCBS Brain Injury Waiver.

Diagnosis:

Date Injury Occurred:

Health Care Provider Information:

Who is your regular doctor?	None
Name		Address

Phone

Date of last visit (if known):

Reason:

Who is your regular dentist?

Name

None

Address

Phone

Date of last visit (if known):

Reason:

Are you seeing any other doctors, such as a psychiatrist, or specialists of any kind?

Yes (list below)

Don’t know

Name

Specialty

Address

Phone

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Section B: Medical and Physical Health

Health Conditions

B1. Overall, how would you rate your physical health?
Excellent	Good	Fair	Poor	No Response
Comments:

B2. Do you have any health problems that require assistance to manage?

Cardiac

Skin Related

G.I. Disorders

Urinary Tract

Weight problems

Evidence of communicable disease

Other – Specify

None

How do they affect you and how long have you had them?

Comments:

B3. Any respiratory problems that require assistance to manage?

Ventilator

Oxygen

Suctioning

Tracheotomy

Cardiorespiratory monitor

Chest physiotherapy

Nebulizer treatment

Other – Specify

None

How do they affect you and how long have you had them?

Comments:

B4. Do you regularly receive any of the following medical treatments?

Days per week

Hours per day

Nursing	no	yes
Physical Therapy	no	yes
Occupational Therapy	no	yes
Speech Therapy	no	yes
Supervision for Safety	no	yes
Diabetes Education	no	yes
Dialysis	no	yes
Respiratory Treatment	no	yes
Catheter Care	no	yes
Colostomy Care	no	yes
Nasogastric Tube Care	no	yes
Other	no	yes

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:

B5. Hearing

No hearing impairment.

Hearing impairment, but managed through assistive devices

Hearing difficulty at level of conversation.

Hears only very loud sounds.

No useful hearing.

Not determined.

Comments:

B6. Vision

Has no impairment of vision.

Vision impairment, but managed through assistive devices

Has difficulty seeing at level of print (far-sighted).

Has difficulty seeing obstacles in environment (near-sighted).

Has no useful vision.

Not determined.

Comments:

B7. Speech/Communication

Communicates independently or impairment has been compensated to function independently.

Communicates with difficulty but can be understood.

Communicates with sign language, symbol board, written messages, gestures or an interpreter.

Communicates inappropriate content, makes garbled sounds, or displays echolalia.

Does not communicate.

Comments:

B8. Sensory Perception (e.g. – taste, smell, tactile, spatial)

No impairment

Impaired – Specify

Comments:

B9. Cognitive Status

Alert and fully oriented

Alert and oriented with significant alteration on self-concept/mood

Generally oriented through use of assistive techniques

Cognitive deficits (e.g. orientation, attention/concentration, perception, memory, reasoning)

Exhibits mental status changes consistent with psychiatric disorder

Comatose, but responsive

Comatose, but unresponsive

Other – Specify

Comments:

B10. Musculoskelatal/Fine or Gross Motor Skills

No Impairment of Musculoskelatal/Fine or Gross Motor Skills
Impaired muscle tone
Contractures
Scoliosis
Paralysis:	Hemiplegia	Paraplegia	Quadriplegia	Other (Specify)

Comments:

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:

Complete This Section For Adults (Age 18 and Over)

B11. Do you have someone who could stay with you for a while if you were sick or needed help?
	Yes (Complete below)	No
	Name:	Relationship:
	Address:
	City, State, Zip code:
	Phone:
B12. Is there anybody you would not want to be involved with your care if you were sick or needed help?
	Yes (Complete below)	No
	Name:	Relationship:


		HEALTH CONDITIONS RISK FACTORS	YES	NO

R1.	Has the consumer had a seizure in the past year?
R2.	Does the consumer have a diagnosis of any other serious medical conditions or other serious health
	concerns (i.e., diabetes, cerebral palsy, heart condition, etc.)?
	If yes, list all conditions/concerns:
R3.	Does the consumer have any life threatening allergies (such as peanuts, bee stings, or shellfish)?
R4. Is the consumer in need of a primary health care provider (or the provider’s contact information is

	unknown)?
	unknown)?
R5.	Is the consumer in need of a dentist (or dentist’s contact information is unknown)?
R6. Is the consumer in need of a specialist (or the specialist’s contact information is unknown)?
R7.	Has the consumer had difficulty making, keeping, or following through with appointments in the last year?

R8.	In the past year, has the consumer gone to a hospital emergency room?
R8.
	If yes, how many times?	Why?
	If yes, how many times?	Why?

R9.	In the past year, has the consumer stayed overnight or longer in a hospital?
	If yes, how many times?	Why?
R10. Is the consumer in need of someone to help if he or she was sick or injured?
Comment on any risk factors marked as “Yes” and address the issue in the Crisis Intervention Plan.			No. of risks:
Comments:

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:
Medication Use
B13. Are you currently taking any prescription medication?		Yes (complete below)		No
Medication Name	Dosage		Frequency		Purpose

Comments:

B14. Are you currently taking any over-the-counter medications on a regular basis (pain relievers, vitamins, laxatives, etc.)?

Yes (complete below) No

Medication Name

Dosage

Frequency

Purpose

Comments:

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:

Complete this section only if the consumer is taking medications.

B15. Are any of your medications kept in a special place, like a locked container or the refrigerator?

Yes No Comments:

B16.	What pharmacy do you use?
B17.	How do you remember to take your medications? (Check all that apply.)
	By following directions	Calendar
	Caregiver gives them	Bubble wrap/Blister Pack
	Medpass Machine	Egg Carton, envelopes	Other:

Comments:

B18. How well do you self-administer medication?

With no help or supervision

With some help or occasional supervision

With a lot of help or constant supervision

Unable to administer own medications/caregiver gives them

Comments:

RN Set-up Pill Minder

MEDICATION ERROR RISK FACTORS

YES

3 = Frequently 2 = Sometimes 1 = Rarely 0 = Never

R11.

Has the consumer had problems with not taking or not receiving medications on time?

R12.

Has the consumer had problems with taking or being given the incorrect number of

medications?

R13. Has the consumer had problems with medications not being refilled on time?

R14. Have there been issues with medications not being re-evaluated timely?

R15.

Has the consumer had significant side effects from medications?

R16.

Has the consumer had significant medication changes in the past year?

R17.

Has the consumer refused or spit out medications?

R18.

Have there been problems with drug interactions?

R19. Has the consumer experienced health problems because of missing/refusing

medications?

R20.

Has the consumer misused prescription or over-the-counter medications (i.e., taken too

many at once)?

R21.

Has the consumer taken another person’s prescription medications?

R22.

Has the consumer used out-dated medications?

R23. Has the consumer used multiple pharmacies or multiple physicians in the past year?

Comment on any risk factors marked as “Yes” and address the issue in the Crisis

No. of risks:

Intervention Plan.

Comments:

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:

Assistive Devices/Special Equipment

B19. Do you use (or need) any of the following special equipment or aids?

None

(If a consumer doesn’t have an item but needs it, mark the “Needs” box)

Uses

Needs

Uses

Needs

Dentures

Hospital bed

Cane

Medical phone alert

Walker

Supplies, e.g. Incontinence pads

Wheelchair (manual, electric)

Bedside commode

Brace (leg, back)

Bathing equipment

Helmet

Lift chair

Communication Devices

Transfer equipment

Hearing aid

Adaptive eating equipment

Glasses/contact lenses

Harness/gait belt

Weighted blankets or vest

Other (Specify):

Comments:

ASSISTIVE DEVICES RISK FACTORS

YES

3 = Frequently 2 = Sometimes

1 = Rarely 0 = Never

R24. Is the consumer in need of assistance with adaptive equipment (need it purchased,

need training, need repairs, etc.)?

R25. Would a power outage interfere with the consumer’s necessary adaptive equipment?

Comment on any risk factors marked as “Yes” and address the issue in the Crisis

No. of risks:

Intervention Plan.

Comments:

Nutrition

B20. How is your appetite?

Good

Fair

Poor

Comments:

B21. Has there been an unexplained weight loss or weight gain in the past year?

Yes (specify in comments)

Comments:

B22. Are there health concerns related to your nutrition?

Yes (specify in comments)

Comments:

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:

B23. Do you have a diagnosed eating disorder (such as overeating, purging, hoarding food)?

Yes (specify in comments)

ASSESSOR: If no, does the consumer’s behavior indicate a possible eating disorder or suggest the need for further evaluation? Yes (specify in comments)

Comments:

B24. Do you have any problems that make it difficult to eat?		Yes (complete below)	No
Dental problems		Can’t eat certain foods
Swallowing problems		Problem with gag reflex
Texture Aversions		Sensitive stomach/nausea
Taste problems		Tube feeding (some or all of the time)
Any other eating problems? (Describe)
Comments:
B25. Are you on a special diet:	Yes (complete below) No
Low salt		Calorie supplement
Low fat		Gluten Free
Low sugar		Milk/lactose free
Weight Loss		Altered Consistency
Other special diet? (Describe)
Comments:

	NUTRITION RISK FACTORS	YES		NO
	NUTRITION RISK FACTORS
	3	2	1	0
3 = Frequently 2 = Sometimes	1 = Rarely 0 = Never

R26. Is the consumer at risk of choking or other problems when eating?

R27. Is the consumer’s health at risk due to poor nutrition (e.g.- eating disorder, refusal to eat, inability to afford nutritious food, etc.)?

R28.	Is the consumer (or the caretaker) ever non-compliant with the prescribed diet?
R29.	Would the consumer’s health be at risk if his or her diet is not strictly followed?
Comment on any risk factors marked as “Yes” and address the issue in the Crisis		No. of risks:
Intervention Plan.
Comments:

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:

Daily Living Skills

B26. Daily Living Skills

	Activity	Independent	Supervision or	Physical	Total
			Verbal	Assistance	Dependence
			Prompts/Cueing

a.	Eating

b.	Grooming & personal
	hygiene

c.	Bathing

d.	Dressing

e.	Mobility in bed

f.	Transferring

g.	Walking

h.	Stair climbing

i.	Mobility with
	wheelchair

Frequency

Daily			Intermittent

Comments (note use of assistive devices or adaptive equipment needed to demonstrate skill):

B27. Toilet Use

Continent – Bowel and bladder

Continent with verbal or physical prompts

Continent except for specified periods of time (e.g. enuresis)

Incontinent – bladder

Incontinent – bowel

Catheter or -ostomy (e.g. suprapubic catheter, colostomy, ileostomy)

Inappropriate toileting habits (e.g. fails to close door, use toilet paper, or wash hands, etc.)

Comments:

	DAILY LIVING SKILLS RISK FACTORS	YES		NO
	DAILY LIVING SKILLS RISK FACTORS
	3	2	1	0
3 = Frequently 2 = Sometimes	1 = Rarely 0 = Never

R30. Is the consumer’s health at risk due to poor hygiene?

R31. Is the consumer at risk for falling?

In the past year has the consumer fractured a bone?

If yes, how did this occur?

R32. Is the consumer at risk of being dropped or injured during transfer?

Comment on any risk factors marked as “Yes” and address the issue in the Crisis	No. of risks:
Intervention Plan.
Comments:

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:

Consumer Needs, Wants, and Desired Results

Related to Medical and Physical Health

What are your strengths and abilities related to your medical and physical health?

ASSESSOR: List any other strengths and abilities not mentioned by the consumer or guardian:

Do you have any other needs related to your medical and physical health that haven’t been addressed above? ASSESSOR: List any other needs related to medical and physical health not mentioned by the consumer or guardian. Do you have any wants related to your medical and physical health?

What are your desired results related to your medical and physical health?

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Section C: Mental Health, Behavioral & Substance Use

Emotional and Mental Health

C1. Have you ever been diagnosed with a mental illness?

Yes

If yes, what is it?

C2. Have you received mental health services in the past?

Yes

If yes, describe:

C3. Are you currently receiving any mental health services or counseling?

Yes (If yes, complete below)

Provider Name and Address

Comments

C4. Emotional Assessment. How have you been feeling during the past month?

Yes

Are you satisfied with your life today?

Have you been depressed or very unhappy?

Have you been feeling like you have too much energy or can’t stop being busy?

Have you been anxious?

Have you had mood swings?

Have you had difficulty sleeping?

Have you felt unmotivated or felt a lack of energy?

Have you felt lonely or isolated?

Comments:

C5. ASSESSOR: Other mental health symptoms.

Yes

Has the consumer had hallucinations (seen or heard things that weren’t really there)?

Has the consumer reported feelings of paranoia?

Has the consumer had delusions (irrational thoughts that weren’t true)?

Comments:

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:

Complete This Section For Children (Age 17 and Under)

C6. Has the child experienced difficulty in interpersonal relationships within the family?
Yes	No
Comments:
C7. Does the parent/guardian exhibit mental health related concerns?
Yes	No
If yes, is he/she currently receiving treatment and following through with treatment?
Yes	No
Comments:

Behavioral
C8. ASSESSOR: Behavioral Assessment.
Behavioral Issue		Does not	Has been modified to	May require verbal or
		exhibit	socially acceptable	physical intervention
			levels
Has episodes of disorientation, being withdrawn, or similar behaviors
Noncompliance with rules or directions
Physically abusive to self
Verbally aggressive toward others
Physically aggressive toward others
Exhibits disruptive behavior (e.g. arguing, shouting, etc.)
Exhibits destructive behavior (e.g. destroying property, burning, etc.)
Exhibits stereotypical, repetitive behavior (e.g. rocking, twirling
fingers or objects, etc.)
Obsessive/compulsive behavior
Antisocial behavior (e.g. lying, stealing, inappropriate touching, etc.)
Wanders into private areas, or habitually elopes
Acts in a sexually inappropriate or aggressive manner
Engages in excessive liquid consumption
Comments:

Alcohol/Tobacco/Substance Use

C9. Do you drink any alcoholic beverages?

Yes

If yes, on average, counting beer, wine, and other alcoholic beverages, how many drinks do you have each day?

Comments:

C10. Do you smoke or use tobacco?

Yes

If yes, how much and how often? (frequency per day)

Comments:

C11. Has tobacco use caused you any problems?

Yes

If yes, please describe:

Comments:

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:

C12. Do you use any other illegal substances such as marijuana, cocaine, or amphetamines?

Yes

If yes, specify:

Comments:

C13. Are the people who are involved in your life (spouse, parents/guardian, friends, etc.) concerned about your alcohol/tobacco/substance use?

Yes

If yes, explain:

Comments:

C14. Do you live with or spend time with a person that has alcohol/substance abuse concerns, including misuse of prescription medication? (For children, this includes the parent/guardian)

Yes

If yes, specify:

Comments:

C15. ASSESSOR: Does the person need education about substance use/abuse?

Yes

If yes, please describe:

Comments:

C16. ASSESSOR: Are you concerned about the person’s alcohol/tobacco/substance use?

Yes

Comments:

MENTAL HEALTH/BEHAVIORAL/SUBSTANCE USE RISK FACTORS

YES

3 = Within the last 6 months 2 = Within the last year 1 = more than 1 year ago 0 = Never

R33.

Has the consumer ingested foreign objects or been diagnosed with PICA?

R34. Has alcohol use caused the consumer any problems?

R35. Has substance use caused the consumer any problems?

R36.

Has the consumer engaged in self-injurious behaviors?

R37.

Has the consumer left or attempted to leave home or other supervised activities

without permission, or when it would be unsafe to do so?

R38.

Has the consumer been aggressive toward others?

R39.

Has the consumer used weapons or objects to hurt self or others? (If 3 or 2, assure

that referral has been made to a qualified mental health professional)

R40.

Has the consumer threatened suicide or made suicidal gestures? (If 3 or 2, assure

that referral has been made to a qualified mental health professional)

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:

MENTAL HEALTH/BEHAVIORAL/SUBSTANCE USE RISK FACTORS		YES		NO
MENTAL HEALTH/BEHAVIORAL/SUBSTANCE USE RISK FACTORS
	3	2	1	0
3 = Within the last 6 months 2 = Within the last year	1 = more than 1 year ago 0 = Never

R41. Has the consumer attempted suicide? (If 3 or 2, assure that referral has been made to a qualified mental health professional)

R42. Has the consumer engaged in criminal behavior?

R43. Has the consumer had a significant life change or event occur?

R44. Does the consumer have a history of other life-threatening behaviors?

	Specify:
	Comment on any risk factors marked as “Yes” and address the issue in the Crisis	No. of risks:
	Intervention Plan.
	Comments:
C17. ASSESSOR: In your opinion would this person benefit from a:
	Mental health referral
	Mental health evaluation
	Substance abuse referral
	Substance abuse evaluation
	Referral for a behavioral assessment
	Other (specify):
	None
Comments:

Consumer Needs, Wants, and Desired Results

Related to Mental Health, Behavior, or Substance Abuse

What are your strengths and abilities related to mental health, behavior, or substance abuse?

ASSESSOR: List any other strengths and abilities not mentioned by the consumer or guardian:

Do you have any other needs related to mental health, behavior, or substance abuse that haven’t been addressed above?

ASSESSOR: List any other needs related to mental health, behavior, or substance abuse not mentioned by the consumer or guardian.

Do you have any wants related to mental health, behavior, or substance abuse?

What are your desired results related to mental health, behavior, or substance abuse?

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Section D: Housing and Environment

D1. What is your current housing type?

Own Home (includes parent/guardian’s home for children)

Friend/Relative Home

Foster Care

RB-SCL

RCF

RCF-PMI

RCF-MR

ICF-MR

ICF/Nursing Facility

MHI

Skilled Nursing Facility

Homeless

Jail

Other (specify):

Comments:

D2. What is your current living arrangement?

Living Alone

Living with Family/Friend

Living with Spouse/Significant Other

Living with Parents

Living in Congregate Setting

Other (specify):

Comments:

D3. Would you like to continue to live where you do now, or is there somewhere else you would prefer to live?

Continue to live here

Don’t know

Prefer to live elsewhere (Specify and briefly describe the barriers, if any:)

Comments:

D4. Is there someone who regularly helps you care for your home or yourself, or who regularly helps with errands or other things? (For children, do NOT include the parent/guardian, but do include others who assist the parent/guardian.)

Yes

If yes, how often?

Caregiver’s Name:

D5. Do you have any home modifications? Check all that apply:
Safe Room	Shatter Proof Windows
Door/Window Alarms	Fenced yard
Wheelchair Ramp	None
Other (specify):

Are any home modifications needed?

Yes (specify):

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:

Complete This Section For Children (Age 17 and Under)

(If the child is currently living in a institutional setting, skip questions D6 through D9 and not the living situation in the comment section below.)

D6. Does the family with whom the child is residing have a stable housing situation?	Yes	No
If not, does the family need assistance in identifying additional resources?

D7. Does the parent/guardian have a physical disability that impairs his/her ability to meet the child’s needs? If yes, what have the parents done to ensure the child’s needs are being met consistently?

D8. Does the family have adequate financial resources?

Yes

If not, does the family need assistance in identifying additional resources?

Yes

D9. Does the child have his or her own money? Where does it come from?

Other Comments:

Yes

Independent Living Skills

D10. How well can you prepare meals for yourself? (Meals may include sandwiches, pre-cooked meals and TV dinners.)

Need no help or supervision

Need some help or occasional supervision

Need a lot of help or constant supervision

Can’t do it at all

Comments:


D11.	Do you know your telephone number?
Yes		No	N/A
D12.	Do you know your address?
Yes		No	N/A
D13.	ASSESSOR: Can this consumer be left without supervision?
Yes		No	N/A
If yes, for how long?

D14. How well are you able to answer the telephone?

Need no help or supervision

Need some help or occasional supervision

Need a lot of help or constant supervision

Can’t do it at all

Comments:

D15. How well are you able to make a telephone call?

Need no help or supervision

Need some help or occasional supervision

Need a lot of help or constant supervision

Can’t do it at all

Comments:

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:

D16. How well can you handle your own money? (understands use of money, can pay for things, can pay bills, can balance the checkbook, etc. as appropriate for age)

Need no help or supervision

Need some help or occasional supervision

Need a lot of help or constant supervision

Can’t do it at all

Comments:

D17. How well can you manage shopping for food and other things you need?

Need no help or supervision

Need some help or occasional supervision

Need a lot of help or constant supervision

Can’t do it at all

Comments:

Complete This Section For Adults (Age 18 and Over)

D18. How well can you manage to do light housekeeping, like dusting or sweeping?

Need no help or supervision

Need some help or occasional supervision

Need a lot of help or constant supervision

Can’t do it at all

Comments:

D19. How well can you do heavy housekeeping, like yard work, or emptying the garbage?

Need no help or supervision

Need some help or occasional supervision

Need a lot of help or constant supervision

Can’t do it at all

Comments:

D20. How well can you do your own laundry, including putting clothes in the washer or dryer, starting and stopping the machine, and drying the clothes?

Need no help or supervision

Need some help or occasional supervision Need a lot of help or constant supervision

Can’t do it at all

Comments:

D21. ASSESSOR: Does the consumer have deficits that pose a threat to his/her ability to live in the community?

Yes No Unsure

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:

Complete This Section For Children (Age 17 and Under)

D22. Does the child do chores? If yes, what are they?

Yes

How independent is the child in completing chores?

Need no help or supervision

Need some help or occasional supervision

Need a lot of help or constant supervision

Can’t do it at all

Comments:


		HOUSING AND ENVIRONMENTAL SAFETY RISK FACTORS				Yes			No


	R45.	Would this consumer’s health be at risk if a paid provider or natural support person did not
		show up to provide scheduled services?
	R46.	Is the consumer at risk at home because of any of these conditions:


			structural damage


			barriers to accessibility (steps, etc.)


			electrical hazards


			signs of careless smoking


			insects or pests


			poor lighting


			insufficient water or no hot water


			insufficient heat


			fire hazards


			tripping hazards


			unsanitary conditions
	R47.	Does the consumer need to be supervised at all times?

	R48.	Is the consumer without means of communication (no phone or PERS)?
	R48.



		For the following items use: 3 = Frequently 2 = Sometimes 1 = Rarely 0 = Never


	R49.	Is the consumer unable to respond to emergencies independently?		3			2	1		0
	R49.
		If consumer is never left alone, mark not applicable:	N/A

	R50.	Is the consumer physically stronger than any of his/her caregivers?

	R51.	Does the consumer lack awareness of dangerous/emergency situations?

	R52.	Does the consumer put him/herself in danger due to careless or risky behaviors (careless
	R52.
		smoking, leaving doors unlocked, etc.)?



	R53.	Is the consumer isolated (lack of transportation, lack of social network)?

	R54.	Is the consumer’s neighborhood unsafe (high risk of crime, etc.)?
	R54.
	R55.	Is the consumer at risk in the community due to unsafe behaviors?

	Comment on any risk factors marked as “Yes” and address the issue in the Crisis				No. of risks:
	Intervention Plan.
	Comments:
			22
Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:

Abuse/Neglect

D23. ASSESSOR: Does the consumer have a history of incidents that have resulted in injury or threat of injury in the past year? (Consult incident reports as necessary)

Yes

If yes, are the causes of the incidents covered in the Crisis Intervention Plan?

Yes

No (specify why not):

ABUSE/NEGLECT RISK FACTORS

YES

3 = Within the last 6 months 2 = Within the last year 1 = more than 1 year ago 0 = Never

R56.

Has the consumer been physically abused?

R57.

Has the consumer been sexually abused?

R58.

Has the consumer been emotionally or psychologically abused?

R59.

Is there evidence of neglect to the consumer by a caregiver?

R60.

Is there evidence of neglect by the consumer (self neglect)?

R61.

Has the consumer been denied basic necessities?

R62.

Has the consumer witnessed abuse or neglect of another person, including domestic

violence?

R63.

Would the consumer be an “easy target”?

Comment on any risk factors marked as “Yes” and address the issue in the Crisis

No. of risks:

Intervention Plan.

Comments:

Consumer Needs, Wants, and Desired Results

Related to Housing and Environment

What are your strengths and abilities related to your housing and environment?

ASSESSOR: List any other strengths and abilities not mentioned by the consumer or guardian:

Do you have any other needs related to your housing and environment that haven’t been addressed above? ASSESSOR: List any other needs related to housing and environment not mentioned by the consumer or guardian. Do you have any wants related to your housing and environment?

What are your desired results related to your housing and environment?

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Section E: Social

E1. Do you feel you need help with social skills?

Yes

Comments:

E2. What is a typical day like for you? (or ask: What do you usually do, starting from the morning?)

What, if anything, would you change about your typical day?

Comments:

E3. What activities or things do you enjoy doing?

Are there activities you enjoy that you would like to do more frequently?

Yes

If yes, what are they?

Is anything needed to support or help you to do these activities?

Yes

If yes, what?

Comments:

E4. If you choose to practice a religion, are able to attend as often as desired?

Yes (Specify where):

N/A

Comments:

E5. ASSESSOR: Does the consumer have knowledge or self-concept of his or her own sexuality appropriate to age level?

Yes

Comments:

E6. Do you communicate with friends, relatives, or others (not including paid helpers) as often as you would want?

Yes

By what means (phone, email, etc)?	How Often?
Comments:

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:

Complete This Section For Adults (Age 18 and Over)

E7.	Do you spend time with others who do not live with you as often as you would want?
	Yes	No
	Comments:
E8.	Do you have someone to confide in when you have a problem?
	Yes	No
	If yes, specify name and relationship:

Complete This Section For Children (Age 17 and Under)

E9. Who are your friends?

E10. What do you like to do with them?

E11. Where do you see your friends?

E12. Do you and your parents agree on your choice of friends?

Yes No

If no, why not?

Consumer Needs, Wants, and Desired Results

Related to Social Functioning

What are your strengths and abilities related to your social functioning?

ASSESSOR: List any other strengths and abilities not mentioned by the consumer or guardian:

Do you have any other needs related to your social functioning that haven’t been addressed above?

ASSESSOR: List any other needs related to social functioning not mentioned by the consumer or guardian.

Do you have any wants related to your social functioning?

What are your desired results related to your social functioning?

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Section F: Transportation

F1. Do you need help with transportation?

Yes

If yes, when and where:

F2. How do you get to the places you want to go? (Check all that apply).

Walk

Bicycle

Drive

Take a bus or taxi

Friend or family member drives

Staff/Provider

Other:

Comments:

F3. How well are you able to use public transportation or drive to places beyond walking distance?

Need no help or supervision

Need some help or occasional supervision

Need a lot of help or constant supervision

Not Available

Can’t do it at all

Comments:

F4. Are there any vehicle modifications needed?

Yes

If yes, specify:

Comments:

Consumer Needs, Wants, and Desired Results

Related to Transportation

What are your strengths and abilities related to transportation?

ASSESSOR: List any other strengths and abilities not mentioned by the consumer or guardian:

Do you have any other needs related to transportation that haven’t been addressed above?

ASSESSOR: List any other needs related to transportation not mentioned by the consumer or guardian.

Do you have any wants related to transportation?

What are your desired results related to transportation?

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Section G: Education

G1. Are you currently in school?

Yes

If yes, specify where:

If no, and the consumer is a child, why not?

Comments:

G2. If in school, are you involved in any extra-curricular activities?

Yes

N/A

If yes, specify:

Comments:

G3. ASSESSOR: Is the consumer able to:

Yes No Comments

Read?

Write?

Sign his/her name?

G4. Are you interested in furthering your education?

Yes

If yes, what area do you want to further your education in?

Comments:

G5. Do you need assistance or support in gaining access to educational services?

Yes

If yes, please specify what type of assistance is needed:

Comments:

G6. ASSESSOR: Does the consumer have any intellectual or cognitive difficulties?

No intellectual problems

Has difficulties but is able to function with minimal assistance or adaptive devices

Has intellectual problems requiring verbal or physical assistance (check all that apply):

Difficulty with or unable to tell time

Does not know survival words or signs

Problems with reading

Problems with writing

Difficulty with number skills

Difficulty with reasoning and problem solving

Memory problems Other – specify

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment
Consumer Name:
Complete This Section For Adults (Age 18 and Over)
G7. What is the highest level of education you have completed?
Less than High School	Trade School
Some High School	Some College
GED	College Graduate
Graduated Special Education	Graduate Degree
High School Graduate	Unknown
Comments:

Complete This Section For Children (Age 17 and Under)
G8. What grade are you in?	N/A

G9. Do you like school?

Yes

N/A

	If no, why not?
G10.	ASSESSOR: Is the child following the school’s attendance policy?
	Yes
	No
	N/A
	If no, what are the circumstances?
G11.	ASSESSOR: Does the child have a Special Education Plan?
	Yes (specify):	IEP	504 Plan
	No
	N/A
G12.	ASSESSOR: Is there an aide or mentor assigned to the child?
	Yes
	No
	N/A
G13.	ASSESSOR: Is the child on target to graduate with his or her class?
	Yes
	No
	N/A

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:

Consumer Needs, Wants, and Desired Results

Related to Education

What are your strengths and abilities related to education?

ASSESSOR: List any other strengths and abilities not mentioned by the consumer or guardian: Do you have any other needs related to education that haven’t been addressed above? ASSESSOR: List any other needs related to education not mentioned by the consumer or guardian. Do you have any wants related to education?

What are your desired results related to education?

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Section H: Vocational

Complete this section for consumers age 14 or older.

H1. Do you work?

Yes

N/A

Comments:

Questions for consumers who are currently working:

H2. What is your current work setting?

	Where Employed:
Competitive employment: full-time
Competitive employment: part-time
Supported Employment
Enclave
Sheltered work
If competitively employed, do you use natural supports in the work environment?		Yes	No
Comments:
H3. Are you happy in your current job?
Yes
No
If no, what job would you like to do?
Why does this job appeal to you?
Comments:
Questions for consumers who are not currently working:
H4. Are you able to work in the community?
Yes
No
Comments:
H5. Do you want to work in the community?
Yes
No
If yes what job would you like to do?
Why does this job appeal to you?
Comments:

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:

Question for consumers who are working, or who are not working but are willing and able to work:

H6. Do you need help in any of the following areas?

Yes

Looking for and obtaining a job

Job interviewing

Attending work as scheduled

Arriving to work on time and returning to work after lunch and breaks

Being appropriately dressed and groomed for work

Accepting work assignments and completing them according to instructions

Independently initiating work

Attending to work tasks without distraction

Following written directions

Performing a 1-step task

Performing a 2-3 step task

Communicating wants or needs

Timely informing employer when going to miss work

Accepting changes in schedule or routine

Getting along with co-workers

Other, including any barriers to obtaining employment:

Comments:

Consumer Needs, Wants, and Desired Results

Related to Vocational Functioning

What are your strengths and abilities related to your vocational functioning?

ASSESSOR: List any other strengths and abilities not mentioned by the consumer or guardian:

Do you have any other needs related to your vocational functioning that haven’t been addressed above?

ASSESSOR: List any other needs related to vocational functioning not mentioned by the consumer or guardian.

Do you have any wants related to your vocational functioning?

What are your desired results related to your vocational functioning?

Form 470-4694 (Rev. 1/10)

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completing case management intake assessment form sample stage 1

Note the appropriate information in Basis of Case Management, CM, I BI Waiver, Elderly Waiver CM, H Waiver, VERIFICATION OF H, CBS WAIVER, Home- and Community, Based Services, My right to choose a Home- and, Medical Institutional Services, H, CBS, Date, and Form 470, 4694 (Rev area.

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