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.

QuestionAnswer
Form NameCase Management Assessment Template
Form Length31 pages
Fillable?Yes
Fillable fields1644
Avg. time to fill out37 min 24 sec
Other namescase 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

 

 

 

 

 

1

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

No

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:

 

2

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:

 

 

 

 

 

 

 

 

 

3

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

No

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

No

4

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)

No

Don’t know

Name

Specialty

Address

Phone

5

Form 470-4694 (Rev. 1/10)

How to Edit Case Management Assessment Template Online for Free

We have used the efforts of our best programmers to build the PDF editor you intend to apply. The software allows you to fill in the case document forms document effortlessly and don’t waste precious time. All you should undertake is follow the following easy tips.

Step 1: The following website page contains an orange button stating "Get Form Now". Select it.

Step 2: After you have entered the case document forms editing page you'll be able to discover all of the options you may conduct concerning your file from the upper menu.

For every single part, add the information demanded by the program.

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.

Entering details in case management intake assessment form sample part 2

Note down the significant particulars when you're within the Name, Title (if applicable), Relationship to Consumer, Additional records reviewed:, Female, Male, Comments: Monthly Income: (Please, Source, SSI S, SDI Employment Other, Yes, and Amount section.

step 3 to entering details in case management intake assessment form sample

The SSI S, SDI Employment Other, Comments: Court Involvement:, Involuntary Commitment Probation, and Comments: box will be the place to indicate the rights and obligations of each side.

Finishing case management intake assessment form sample part 4

Finish by reading the following fields and preparing them correspondingly: Consumer Name: Legal decision, None, Guardian, Attorney, in, fact Other (Specify):, Name: (First, Work Phone:, Cell Phone:, Guardian, Attorney, in, fact Other (Specify):, Cell Phone:, Yes, (complete below), and Work Phone:.

Filling out case management intake assessment form sample stage 5

Step 3: When you are done, choose the "Done" button to upload your PDF form.

Step 4: Generate copies of your document. This is going to prevent possible challenges. We cannot see or publish your details, thus you can relax knowing it is protected.

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