Soc 821 PDF Details

In the heart of California's efforts to provide comprehensive care for individuals with significant mental impairments, the Soc 821 form emerges as a critical document within the realm of the Health and Human Services Agency and the California Department of Social Services. This form serves as a thorough assessment tool for the need for Protective Supervision under the In-Home Supportive Services (IHSS) Program, ensuring individuals who are non self-directing, confused, mentally impaired, or mentally ill receive the observation and monitoring necessary to protect them from potential accidents or hazards. The detailed parameters set forth by the form underscore the program's exclusions, notably highlighting situations where the need for supervision is not applicable, such as physical conditions, social visitations, medical supervision, anticipation of medical emergencies, or to control antisocial behavior. Physicians and medical professionals are guided to provide extensive information regarding the patient's condition, including diagnosis, prognosis, memory deficits, orientation, judgment, and any history of accidents or injuries due to their condition, which underlines the importance of this form in the decision-making process for eligibility of Protective Supervision. Furthermore, the requirement for a physician or medical professional's certification confirms the form's role in leveraging medical expertise to inform social service provisions. People navigating the complexities of caring for mentally impaired individuals can find solace in the SOC 821 form's structured approach to identifying and addressing the need for protective measures that enhance the safety and well-being of some of California's most vulnerable citizens.

QuestionAnswer
Form NameSoc 821
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namessoc 821 form, soc 821 download, soc 821 form for ihss, soc 821 protective supervision form

Form Preview Example

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCYCALIFORNIA DEPARTMENT OF SOCIAL SERVICES

ASSESSMENT OF NEED FOR PROTECTIVE SUPERVISION

■ Release of Information Attached

FOR IN-HOME SUPPORTIVE SERVICES PROGRAM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attending

 

 

PATIENT’S NAME:

 

 

PATIENT’S DOB:

 

 

 

 

 

 

/ /

Physician’s /

 

MEDICAL ID#: (IF AVAILABLE)

 

COUNTY ID#:

 

 

 

 

 

 

 

 

 

 

 

Medical Professional’s

IHSS SOCIAL WORKER’S NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mailing address

COUNTY CONTACT TELEPHONE #:

 

COUNTY FAX #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Your patient is an applicant/recipient of In-Home Supportive Services (IHSS) and is being assessed for the need for Protective Supervision. Protective Supervision is available to safeguard against accident or hazard by observing and/or monitoring the behavior of non self-directing, confused, mentally impaired or mentally ill persons. This service is not available in the following instances:

(1)When the need for protective supervision is caused by a physical condition rather than a mental impairment;

(2)For friendly visitation or other social activities;

(3)When the need for supervision is caused by a medical condition and the form of supervision required is medical;

(4)In anticipation of a medical emergency (such as seizures, etc.);

(5)To prevent or control antisocial or aggressive recipient behavior.

Please complete this form and return it promptly. Thank you for your assisting us in determining eligibility for Protective Supervision.

(Welfare and Institutions Code §12301.21)

DATE PATIENT LAST SEEN BY YOU:

 

LENGTH OF TIME YOU HAVE TREATED PATIENT:

 

 

 

 

DIAGNOSIS/MENTAL CONDITION:

 

PROGNOSIS: ■ Permanent

■ Temporary - Timeframe:__________

 

PLEASE CHECK THE APPROPRIATE BOXES

 

MEMORY

 

 

 

■ No deficit problem

■ Moderate or intermittent deficit (explain below)

■ Severe memory deficit (explain below)

Explanation:_________________________________________________________________________________________________

___________________________________________________________________________________________________________

ORIENTATION

 

■ No disorientation

■ Moderate disorientation/confusion (explain below) ■ Severe disorientation (explain below)

Explanation:_________________________________________________________________________________________________

___________________________________________________________________________________________________________

JUDGMENT

 

 

■ Unimpaired

■ Mildly Impaired (explain below)

■ Severely Impaired (explain below)

Explanation:_________________________________________________________________________________________________

___________________________________________________________________________________________________________

1.Are you aware of any injury or accident that the patient has suffered due to deficits in memory,

orientation or judgment?■ Yes ■ No

If Yes, please specify: ______________________________________________________________________________________

2.Does this patient retain the mobility or physical capacity to place him/herself in a situation which

would result in injury, hazard or accident?

■

Yes ■

No

3.Do you have any additional information or comments?____________________________________________________________

_______________________________________________________________________________________________________

CERTIFICATION

I certify that I am licensed to practice in the State of California and that the information provided above is correct.

SIGNATURE OF PHYSICIAN OR MEDICAL PROFESSIONAL:

MEDICAL SPECIALTY:

DATE:

 

 

 

 

ADDRESS:

LICENSE NO.:

TELEPHONE:

 

 

(

)

 

 

 

 

RETURN THIS FORM TO:

COUNTY’S MAILING ADDRESS, CITY, CA,: ATTN; SW-NAME

SOC 821 (3/06)

How to Edit Soc 821 Online for Free

We were making the PDF editor with the idea of making it as simple to work with as it can be. That's why the entire process of filling out the soc 821 pdf will likely to be smooth use the next steps:

Step 1: To get started, choose the orange button "Get Form Now".

Step 2: You are now on the document editing page. You can edit, add content, highlight particular words or phrases, put crosses or checks, and put images.

Please type in the next information to create the soc 821 pdf PDF:

part 1 to filling in soc 821 form for ihss

Provide the appropriate data in the space MEMORY, Permanent PLEASE CHECK THE, No deficit problem, Severe memory deficit explain, Moderate or intermittent deficit, ORIENTATION, No disorientation, Moderate disorientationconfusion, Severe disorientation explain below, Explanation, JUDGMENT, Unimpaired, Mildly Impaired explain below, Severely Impaired explain below, and Explanation.

part 2 to finishing soc 821 form for ihss

Provide the considerable details the RETURN THIS FORM TO, COUNTYS MAILING ADDRESS CITY, TELEPHONE, and SOC box.

Filling in soc 821 form for ihss part 3

Step 3: When you are done, click the "Done" button to transfer your PDF file.

Step 4: Make sure you keep away from future challenges by preparing no less than 2 duplicates of your form.

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