Family Support Program

If you or an immediate family member has a disability, you may be eligible to receive family support services.

Family Support Services is a program designed and funded by the Tennessee Department of Intellectual and Developmental Disabilities (DIDD) to assist families who are caring for their relative who has a severe disability. Severe disability is defined as:

• Attributable to a mental or physical impairment

• Likely to continue indefinitely

• Result in substantial functional limitations in three or more of the following major life activities:

Self-care Receptive/expressive language
Learning Mobility
Self-direction
Capacity for independent living
Economic self-sufficiency

An essential element of the Family Support Services program is family and consumer involvement. Local councils have been established and meet on a regular basis to oversee and provide advice on the distribution of local services.

Family Support Services may include such things as:

• Respite care

• Personal or attendant services

• Specialized equipment maintenance and repair

• Homemaker services

• Specialized equipment & supplies

• Specialized nutrition & clothing

• Child care

• Health related cost not otherwise covered

• Family counseling training & Support groups

• Transportation services

• Licensed nursing & nurses aid services

HOW TO RECEIVE SERVICES: Eligible Residents of Anderson, Blount, Campbell, Cocke, Knox, Loudon, Morgan, Roane, Jefferson, Sevier and Scott Counties please click the links below for additional information:

EVC Family Support Application

EVC Family Support Letter

State of Tennessee Family Support Service Definitions

State of Tennessee Family Support Brochure

For additional help in receiving services please contact:

Family Support Director, Regina Wilson 865-813-0578

Family Support Specialist, Brandi Neikirk 865-813-0579

Family Support Specialist/Interpreter, Daniel Vargas 865-813-0577

If funding has already been allocated for the current fiscal year, please request that your name be added to the waiting list for that county.

Department of Intellectual and Developmental Disabilities

2020-2021 Family Support Intake Form

Fill out this intake completely and submit. Your intake will only be reviewed if ALL sections are completed.

Date*
MM slash DD slash YYYY
County of Residence*
Name of the person Family Support services are being requested for*
First Last
Family's Address*
Street Address Address Line 2 City State ZIP Code
Date of Birth*
MM slash DD slash YYYY
Name of Parent/Spouse/Legal Rep, if different than above
First Last
Email*
Phone*
Potential Support Services Needed/Requested*
- Before/After Care
- Behavior Services
- Daycare
- Emergency Living Expenses
- Family Counseling
- Health Related
- Homemaker Services
- Home Modifications
- Nursing/Nurses Aide
- Personal Assistance
- Recreation/Summer Camp
- Respite
- Specialized Equipment & Maintenance/Repair
- Specialized Nutrition/Clothing/Supplies
- Training
- Transportation
- Vehicle Modification
- Other
Check all that apply.
Other
Please clarify
Do you (the person applying for Family Support) receive any of the following?*
Check all that apply
- Adoption Assistance
- Food Stamps
- Residential Services
- Social Security Income
- Social Security Disability Income
- Foster Care
- Vocational Rehabilitation
- Nursing Services
- Support Living
- TN Early Intervention System (TEIS)
- PACE (Program of All-Inclusive Care for the Elderly)
- OPTIONS Program
- None
What type of insurance do you (the person applying for Family Support) have*
- Medicaid
- TennCare (Medicaid)
- Private Insurance
- TNCare
- Uninsured
Have you (the person applying for Family Support) applied for or do you receive any of the following?*
Check all that apply
- CHOICES
- ECF CHOICES
- DIDD Waivers
- TBI Grant
- Katie Beckett Program
- Any In Home or Community Supports
- None
To comply with Title VI, the following information is requested:*
- African-American
- Asian
- Caucasian
- Hispanic
- Other
- Unknown
Gender*
- MALE
- FEMALE
Primary Disability*
Check which of the following major disability categories is most relevant to the person requesting Family Support services (as a primary diagnosis)
- Autism
- Cerebral Palsy
- Deaf and/or Blind
- Health Impairment
- Traumatic Brain Injury
- Intellectual Disability
- Neurologic Impairment
- Orthopedic Impairment/Physical Disability
- Spinal Cord Injury
- Developmental Delay (Birth-8 y.o.)
- Other
Notes*
In order for us to understand your needs more clearly, please explain in detail how the Family Support funds would assist your family. Based on the diagnosis of the applicant, what needs is he/she unable to obtain without these supports? How would the applicants daily life be improved with this assistance?
Did the person's primary disability occur*
- Prior to age 22
- At age 22 or after
Acknowledgement
By signing and dating this Intake Form I, the person applying or their legal representative, indicate that all of the information above is true and accurate. Furthermore, I understand that providing invalid, inaccurate, or incomplete information could be considered as fraud and may result in a criminal investigation and disqualification from the program which would prevent re-application in subsequent years.
Signature*
Date
MM slash DD slash YYYY
File Upload (encouraged)
Accepted file types: doc, docx, pages, odt, rtf, tex, txt, wpd, wps, pdf, Max. file size: 128 MB.
If someone other than the family/person is making a referral
Name of person making referral to Family Support
First Last
Agency
Phone
Address
Full Address
Please describe the applicant’s current living situation. Who does he/she live with?
Are there other individuals with disabilities residing in the home?
- Yes
- No
If YES, please describe the relationship to the applicant and the nature of their disability
Please describe how the applicant’s disability affects his/her daily life and his/her family’s life.
Applicant's Self Care & Daily Living Skills
Please check the applicable box for each activity of daily living.
Eating (Does not include meal prep)
- Needs Total Assistance
- Needs Some Assistance
- Needs No Assistance
Please Describe the Assistance needed/provided
Dressing
- Needs Total Assistance
- Needs Some Assistance
- Needs No Assistance
Please Describe the Assistance needed/provided
Bathing
- Needs Total Assistance
- Needs Some Assistance
- Needs No Assistance
Please Describe the Assistance needed/provided
Toileting
- Needs Total Assistance
- Needs Some Assistance
- Needs No Assistance
Please Describe the Assistance needed/provided
Transfers in/out of bed/wheelchair/shower/toilet
- Needs Total Assistance
- Needs Some Assistance
- Needs No Assistance
Please Describe the Assistance needed/provided
Preparing meals
- Needs Total Assistance
- Needs Some Assistance
- Needs No Assistance
Please Describe the Assistance needed/provided
Making medical appointments
- Needs Total Assistance
- Needs Some Assistance
- Needs No Assistance
Please Describe the Assistance needed/provided
Shopping for groceries, taking medications
- Needs Total Assistance
- Needs Some Assistance
- Needs No Assistance
Please Describe the Assistance needed/provided
Completing household chores
- Needs Total Assistance
- Needs Some Assistance
- Needs No Assistance
Please Describe the Assistance needed/provided
Managing money
- Needs Total Assistance
- Needs Some Assistance
- Needs No Assistance
Please Describe the Assistance needed/provided
Applicant’s ability to Communicate
Is the applicant’s ability to communicate affected by their disability?
- Yes
- No
How does the applicant prefer to communicate with others (speaking, assistive device, sign, etc.)? And can others easily understand them?
Does the applicant have difficulty understanding verbal instructions/conversations?
- Yes
- No
Applicant’s ability to Learn
Is the applicant’s ability to learn affected by their disability?
- Yes
- No
If yes, please describe how learning is affected:
Applicant’s Mobility (ability to walk, move around in their home and in the community, manage stairs or uneven terrain)
Is the applicant’s mobility affected by their disability?
- Yes
- No
If YES, how is his/her mobility affected?
Does the applicant require a supportive device (walker, cane, wheelchair, etc.)?
- Yes
- No
If YES, please describe what supportive device is needed:
Applicant’s Self Direction
Is the applicant aware of danger (crossing the street, hot water/stove, stranger danger)?
- Yes
- No
Does the applicant have behavioral or stemming issues?
- Yes
- No
Is the applicant able to tell and manage time?
- Yes
- No
How does the applicant’s disability affect his/her judgement and ability to make decisions?
Does the applicant need constant supervision due to safety concerns?
- Yes
- No
Applicant’s Economic Self-Sufficiency
Is the applicant employed?
- Yes
- No
Are accommodations made so that he/she can work (altered schedule, escort, etc.)
- Yes
- No
If YES, please describe those accommodations:
How does the applicant’s disability affect his/her ability to work?
Comments
This field is for validation purposes and should be left unchanged.

Family Support Program

For additional help in receiving services please contact:

Family Support Director, Regina Wilson 865-813-0578

Family Support Specialist, Brandi Neikirk 865-813-0579

Department of Intellectual and Developmental Disabilities

2020-2021 Family Support Intake Form

Acknowledgement

If someone other than the family/person is making a referral

Applicant's Self Care & Daily Living Skills

Applicant’s ability to Communicate

Applicant’s ability to Learn

Applicant’s Mobility (ability to walk, move around in their home and in the community, manage stairs or uneven terrain)

Applicant’s Self Direction

Applicant’s Economic Self-Sufficiency

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