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Blank Case Management Assessment PDF Form

The Case Management Assessment form is a comprehensive tool designed to gather essential information about individuals seeking case management services. This form collects personal details, medical history, and preferences regarding Home- and Community-Based Services. Completing this form accurately ensures that consumers receive the appropriate support tailored to their unique needs; please fill it out by clicking the button below.

Article Guide

The Case Management Assessment form plays a crucial role in evaluating and documenting the needs of individuals seeking various types of assistance, particularly in the context of home- and community-based services (HCBS). This comprehensive tool gathers essential consumer information, including personal details such as name, address, and contact information, as well as demographic data like age and income sources. It also identifies the consumer's eligibility for different waivers, such as the Brain Injury Waiver or Intellectual Disability Waiver, ensuring that the right services can be tailored to meet their unique circumstances. The form requires input from an interdisciplinary team, highlighting the collaborative nature of case management. Additionally, it addresses medical and mental health histories, providing a holistic view of the consumer's situation. Emergency contacts and legal decision-makers are also documented, ensuring that all necessary parties are informed and involved in the care process. By capturing this extensive information, the Case Management Assessment form serves as a foundational document that helps guide the delivery of appropriate and effective services to those in need.

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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:

Agency:

Address:

Phone:

Signature

Title:

E-Mail:

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)

➤ PDF File

Form Specifications

Fact Name	Details
Form Title	Case Management Comprehensive Assessment
Governing Law	State-specific laws govern the use of this form, typically under Medicaid regulations.
Consumer Information	Section A collects essential details about the consumer, including name, address, and contact information.
Type of Assessment	The form allows for different types of assessments: Initial, Annual, Special, and Demographic Change Only.
Eligibility Basis	Eligibility for case management services is determined based on various categories such as CMI, MR, DD, and BI Waivers.
Consumer Choice Verification	This section ensures that consumers understand their right to choose between HCBS and Medical Institutional Services.
Demographic Data	Demographic information includes gender, language proficiency, and monthly income sources.
Emergency Contacts	Providers must document primary and secondary emergency contacts for the consumer.
Medical Information	Medical and mental health diagnoses must be recorded, along with details about healthcare providers.

Case Management Assessment: Usage Guidelines

Filling out the Case Management Assessment form is an important step in the assessment process. Once completed, this form will help guide the next steps in case management services. Make sure to provide accurate information to ensure a smooth experience.

Start with Section A: Consumer Information. Fill in the consumer's name, current address, Medicaid State ID number, date of birth, county of residence, and contact numbers (home, work, and cell).
Provide the consumer's email address and the assessor's information, including name, title, agency, address, phone, and email.
Indicate the type of assessment by checking the appropriate box (Initial, Annual, Special, or Demographic Change Only). Include the assessment date and discharge date, if applicable, along with the reason for discharge.
Check the basis of case management eligibility by selecting the relevant options (CMI, MR, DD, BI Waiver, Elderly Waiver, CMH Waiver, Habilitation, or MFP).
For consumers applying for HCBS waivers, complete the verification of consumer choice section. Indicate the choice between Home- and Community-Based Services or Medical Institutional Services and sign with the consumer's or guardian's signature and date.
List the interdisciplinary team members consulted, including their names, titles, and relationships to the consumer.
Fill in additional records reviewed and consumer demographics, including gender, language proficiency, and need for interpreter services.
Provide information about the consumer's monthly income sources and amounts, checking all that apply.
Indicate any court involvement, if applicable, and provide comments as needed.
Identify the legal decision maker and co-decision maker, if applicable. Include their names, contact information, and relationships to the consumer.
List emergency contacts, including primary and secondary contacts, along with their relationship to the consumer and contact details.
For adults (age 18 and over), indicate veteran status and marital status, including spouse's name if married.
For children (age 17 and under), provide details about living arrangements, parents' names, marital status, and any relevant comments.
Document medical information, including diagnoses, the name of the professional making the diagnosis, and the date of diagnosis.
Complete mental health information using the DSM-IV-TR axes, including the name and credential of the diagnosing professional and the date of diagnosis.
For consumers applying for the HCBS Intellectual Disability Waiver, provide the most current IQ score or level of functioning.
For those applying for the HCBS Brain Injury Waiver, document the diagnosis and date the injury occurred.
List the consumer's regular healthcare providers, including doctors and dentists, along with their contact information and dates of last visits.
Finally, indicate if the consumer is seeing any other doctors or specialists and provide their names, specialties, and contact information if applicable.

Your Questions, Answered

What is the purpose of the Case Management Assessment form?

The Case Management Assessment form is designed to gather essential information about a consumer's needs, preferences, and circumstances. It helps case managers determine eligibility for various services, including Home- and Community-Based Services (HCBS) and waivers. This comprehensive assessment ensures that consumers receive the appropriate support tailored to their individual situations.

Who needs to complete the Case Management Assessment form?

The form must be completed for individuals applying for case management services, especially those seeking Home- and Community-Based Services or waivers. This includes adults and children with specific needs related to medical, mental health, or developmental disabilities.

What information is required in the Consumer Information section?

The Consumer Information section requires the consumer's name, address, Medicaid State ID number, date of birth, and contact information. Additionally, it asks for details about the assessor, the type of assessment, and relevant dates. This information helps case managers establish a baseline for services and maintain accurate records.

What does the verification of HCBS waiver consumer choice entail?

This section confirms that consumers understand their options regarding Home- and Community-Based Services versus Medical Institutional Services. Consumers or their guardians must indicate their choice by signing the form. This ensures that they are informed and can make decisions that best suit their needs.

How is financial information handled in the assessment?

The assessment collects information about the consumer's monthly income and sources, such as SSI, SSDI, or employment. This financial data is crucial for determining eligibility for various services and ensuring that consumers receive the appropriate level of support based on their financial situation.

What medical information is required in the assessment?

The assessment requires details about any medical diagnoses, including the name of the diagnosing professional and the date of diagnosis. It also collects mental health information, including diagnoses based on the DSM-IV-TR. This comprehensive medical background helps case managers understand the consumer's health needs better.

How does the assessment address the needs of children?

For children under 18, the assessment includes questions about their living situation, parental information, and any siblings who may also be receiving waiver services. This information is vital for understanding the child's environment and ensuring that all family dynamics are considered in the case management process.

What role do emergency contacts play in the assessment?

The assessment asks for emergency contact information, including primary and secondary contacts. This ensures that case managers can reach someone quickly if issues arise or if the consumer requires immediate assistance. Having reliable contacts is essential for effective case management.

What happens after the Case Management Assessment form is completed?

Once the form is completed, case managers review the information to determine eligibility for services. They may also use the data to create a personalized care plan that addresses the consumer's specific needs. Follow-up assessments may occur annually or as circumstances change.

Can the assessment be updated or changed after submission?

Yes, the assessment can be updated if there are significant changes in the consumer's circumstances, such as a change in income, health status, or living situation. It is important to keep the information current to ensure that the consumer receives the most appropriate services.

Common mistakes

Incomplete Consumer Information: Many individuals fail to provide all necessary details in the Consumer Information section. This includes missing the consumer's full name, current address, or Medicaid State ID number. Such omissions can lead to delays in processing and may hinder access to essential services.
Incorrect Selection of Assessment Type: It is crucial to accurately select the type of assessment being conducted. Some people mistakenly choose the wrong option, such as "Initial" instead of "Annual." This can result in confusion and may affect eligibility for services.
Omitting Emergency Contact Information: Failing to include emergency contacts can create significant issues in critical situations. Always ensure that primary and secondary contacts are listed with complete information, including phone numbers and relationships to the consumer.
Not Providing Accurate Medical Information: Some individuals overlook the importance of detailing medical diagnoses and the names of healthcare professionals. Inaccurate or incomplete medical history can impede the assessment process and affect the quality of care provided.
Neglecting to Sign and Date the Form: A common mistake is forgetting to sign and date the form. Without a signature, the assessment may not be considered valid, which can delay necessary services or supports.

Documents used along the form

The Case Management Assessment form is an essential document that helps gather comprehensive information about consumers seeking case management services. Alongside this form, there are several other documents that are frequently used to ensure a complete understanding of the consumer's needs and circumstances. Below is a list of related forms that play a critical role in the case management process.

Individual Service Plan (ISP): This document outlines specific goals, services, and supports tailored to the consumer's unique needs. It is developed collaboratively with the consumer and their support team to ensure that all aspects of their care are addressed.
Eligibility Determination Form: Used to assess whether a consumer qualifies for specific programs or services. This form collects information on financial status, medical needs, and other eligibility criteria necessary for program acceptance.
Consent for Release of Information: This form allows the consumer to authorize the sharing of their personal information with other service providers. It ensures that all parties involved in the consumer's care can communicate effectively and coordinate services.
Progress Notes: These are detailed records that document the consumer's progress towards their goals. They are typically completed by case managers and provide insights into the effectiveness of the services being provided.
Discharge Summary: When a consumer is ready to transition out of services, this document summarizes their journey, the services received, and any recommendations for future care. It helps ensure continuity of care and supports the consumer's ongoing needs.

Utilizing these documents in conjunction with the Case Management Assessment form creates a comprehensive framework for understanding and addressing the needs of consumers. This thorough approach is crucial for effective case management and ultimately enhances the quality of care provided.

Similar forms

Intake Form: Similar to the Case Management Assessment form, an intake form gathers essential consumer information at the beginning of a service relationship. It typically includes personal details, contact information, and initial assessment data.
Service Plan: A service plan outlines the specific services and supports a consumer will receive. Like the Case Management Assessment, it is based on the consumer's needs and preferences, ensuring that care is tailored to individual circumstances.
Eligibility Determination Form: This document assesses whether a consumer meets specific criteria for services. It shares similarities with the Case Management Assessment by evaluating the consumer's background and needs to establish eligibility for programs.
Discharge Summary: A discharge summary provides a comprehensive overview of a consumer's status at the end of services. It parallels the Case Management Assessment by summarizing key information and outcomes, helping to inform future care needs.
Progress Notes: Progress notes document ongoing interactions and developments in a consumer's care. They are similar to the Case Management Assessment in that they track changes over time and inform future assessments and service planning.

Dos and Don'ts

When filling out the Case Management Assessment form, it is important to follow certain guidelines to ensure accuracy and completeness. Here are four recommendations on what to do and what to avoid:

Do ensure all personal information is accurate. Double-check names, addresses, and contact details to avoid any discrepancies.
Do provide complete medical information. Include all relevant diagnoses and healthcare provider details to facilitate proper assessment.
Do consult with the consumer or their legal representative. It is crucial to involve them in the process to ensure their preferences and needs are accurately represented.
Do keep a copy of the completed form. Retaining a copy can be helpful for future reference and follow-up.

Don't rush through the form. Take your time to ensure every section is filled out thoughtfully and thoroughly.
Don't leave any sections blank. If a question does not apply, indicate that clearly rather than omitting it.
Don't use abbreviations or shorthand. Clear and complete responses are essential for understanding.
Don't forget to sign and date the form. An unsigned form may delay processing and assessment.

Misconceptions

Misconceptions about the Case Management Assessment form can lead to confusion and misinterpretation of its purpose. Here are six common misunderstandings:

The form is only for new consumers. Many believe that the Case Management Assessment form is only necessary for individuals seeking services for the first time. In reality, it is also used for annual reviews and special assessments, ensuring ongoing support for existing consumers.
All information is mandatory. Some individuals think that every section of the form must be filled out completely. While comprehensive information is helpful, certain sections may not apply to everyone, and it is acceptable to leave them blank if they do not pertain to the consumer.
The form is only focused on medical history. A common misconception is that the assessment is solely about medical information. However, it also includes personal details, financial status, and social circumstances, all of which are vital for effective case management.
Consumers cannot choose their services. There is a belief that the form dictates what services a consumer must accept. In fact, it includes a section where consumers can express their choice between Home- and Community-Based Services and Medical Institutional Services, empowering them to make informed decisions.
Only professionals can fill out the form. Some think that only case managers or healthcare professionals can complete the assessment. In truth, consumers and their guardians can contribute information, making it a collaborative effort.
The form is a one-time requirement. Many assume that once the assessment is completed, no further action is needed. However, regular updates and annual assessments are crucial to adapt to any changes in the consumer's needs or circumstances.

Understanding these misconceptions can help consumers and their families navigate the assessment process more effectively and ensure they receive the appropriate services and support.

Key takeaways

Filling out and utilizing the Case Management Assessment form is crucial for ensuring that consumers receive the appropriate services they need. Here are some key takeaways to consider:

Accurate Information: Ensure that all consumer information, including name, address, and contact details, is filled out accurately to avoid any delays in service delivery.
Eligibility Basis: Clearly indicate the basis for case management eligibility, whether it’s due to a specific waiver or other criteria.
Verification of Consumer Choice: Complete the section regarding Home- and Community-Based Services (HCBS) carefully, as it reflects the consumer's preferences and rights.
Interdisciplinary Team: List all team members consulted during the assessment process. This promotes collaboration and a comprehensive understanding of the consumer's needs.
Financial Information: Document the consumer's monthly income sources accurately, as this information is vital for determining eligibility for various services.
Emergency Contacts: Include emergency contact information for primary and secondary contacts to ensure swift communication in case of urgent needs.
Medical Information: Provide thorough details about the consumer’s medical and mental health diagnoses, including the names of professionals who made these diagnoses.
Child-Specific Information: For consumers who are children, include details about their living situation and parents, as this information is essential for case management.
Signature Requirement: Ensure that the consumer or their legal representative signs the form, as this validates the information provided and the choices made.
Review and Update: Regularly review and update the form, especially during annual assessments or when significant changes occur in the consumer’s circumstances.

By following these guidelines, the assessment process can be streamlined, ensuring that consumers receive the necessary support and services tailored to their individual needs.