In late February, Washington State's Department of Social and Health Services (DSHS) released Form Dshs 14 299. The form is designed to help DSHS staff members determine whether an individual has a significant mental disorder that would disqualify them from being able to care for a child. According to DSHS, the form will also help staff identify children who may be in need of protection due to a parent or guardian's mental disorder. The form is not available to the public and was created specifically for DSHS staff use.
| Question | Answer |
|---|---|
| Form Name | Form Dshs 14 299 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | 14_299 adatsa adult assessment form |
ADATSA/ADULT ASSESSMENT REFERRAL
REFERRING CSO
DATE
SECTION A. IDENTIFYING INFORMATION
1. |
CLIENT LAST NAME |
FIRST NAME |
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MIDDLE NAME |
2. DATE OF BIRTH |
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3. |
ACES CLIENT NUMBER |
4. GENDER |
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5. SOCIAL SECURITY NUMBER |
6. CLIENT TELEPHONE |
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Male |
Female |
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MESSAGE NUMBER |
7. LIMITED ENGLISH PROFICIENCY? |
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No |
Yes; Primary language: |
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8. |
STREET ADDRESS |
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CITY |
STATE |
ZIP CODE |
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SECTION B. ASSESSMENT APPOINTMENT INFORMATION |
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1. |
NAME OF ASSESSMENT CENTER/ENTITY |
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2. TELEPHONE NUMBER |
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3. |
STREET ADDRESS |
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CITY |
STATE |
ZIP CODE |
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4. |
APPOINTMENT DATE |
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5. APPOINTMENT TIME |
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PLEASE NOTE: Take this form (and any attachments) with you to your appointment. Failure to keep this appointment may result in denial, delay or termination of your benefits. Failure to accept a program of treatment as prescribed by the assessment center means you refuse treatment, which may result in denial, termination, and possible sanction. If you have questions about treatment requirements, please ask your CSO worker.
SECTION C. TO ASSESSMENT CENTER
1. |
DATE OF APPLICATION |
2. NAME OF REFERRING AGENCY, OTHER THAN CSO (I.E., HOSPITAL, |
3. AGENCY TELEPHONE NUMBER |
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JAIL, DETOX, ETC., IF APPLICABLE) |
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4. |
CLIENT TYPE (CHECK ALL THAT APPLY) |
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TANF |
PPW |
ADATSA |
SSI/ABD cash |
MCS |
Other: |
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5. |
PRIORITY GROUP: |
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Pregnant |
CPS Referral |
I.V. Drug |
HH/Children |
2082 |
Regular ADATSA (No Priority) |
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6.THE ABOVE NAMED CLIENT IS (Check appropriate box):
Applicant |
Current Recipient |
Transfer from another program |
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A. Client is Title XIX CNP eligible. PROVIDER ONE NUMBER: |
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TANF |
SSI |
ABD |
Other: |
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OR |
Attach printout of medical coverage. |
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B. Applying only for ADATSA Service
C. ABD cash eligibility established
D. MCS medical eligibility established
E. Other reasons this client is being referred?
7.
Other incapacity/health problems:
A. Other evaluation pending (indicate type and date scheduled):
B. Medical/psychological information attached. Screening information attached. C. Special needs for this client. Describe:
8. Comments/Other:
9. FINANCIAL WORKER/CASE MANAGER
TELEPHONE NUMBER
10. CASE WORKER
TELEPHONE NUMBER
COPIES TO: Client File; Client; Assessment Center
DSHS
INSTRUCTIONS
The initiating worker:
1.Enters the referring community Services Office (CSO) name and current date.
2.Completes Section A, including the client’s full name. The full middle name (not just initial) is requested.
3.Completes Section B when the assessment appointment is established.
4.Completes Section C:
A.Item 1 designates date the application was initiated.
B.Completes Items 2 and 3 by entering the name and telephone number of the agency or other entity that prompted the individual to seek chemical dependency services.
C.Item 4 designates client’s program type(s).
D.Completes Item 5 designating the client’s priority category by:
1)Checking “Pregnant” for anyone currently pregnant or up to two months postpartum;
2)Checking “CPS Referral” for anyone that is a direct referral for chemical dependency services from Children Protective Services;
3)Checking “I.V. Drug” for anyone that is an intravenous drug user;
4)Checking “HH/Children” for individuals with children in the home;
5)Checking “No Priority” for everyone not included in the first four priorities.
NOTE: If the client is pregnant, contact the local assessment center immediately for an assessment, as these individuals are fast tracked through the assessment process.
E.Completes either A, B, or C in Item 6, as appropriate. If Item A is checked, indicate Title XIX the Provider One number for medical coverage.
5.Completes Items 7 and 8 as needed. Checks Item 7C if the client has a special need.
6.Completes Items 9 and/or 10 with the names and telephone numbers of the referring financial and social workers.
DSHS