Family Support Program 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Social Security #* 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. OtherPlease 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 AcknowledgementBy 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: 64 MB.If someone other than the family/person is making a referralName of person making referral to Family Support First Last Agency PhoneAddress 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 disabilityPlease describe how the applicant’s disability affects his/her daily life and his/her family’s life.Applicant's Self Care & Daily Living SkillsPlease 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/providedDressing Needs Total Assistance Needs Some Assistance Needs No Assistance Please Describe the Assistance needed/providedBathing Needs Total Assistance Needs Some Assistance Needs No Assistance Please Describe the Assistance needed/providedToileting Needs Total Assistance Needs Some Assistance Needs No Assistance Please Describe the Assistance needed/providedTransfers in/out of bed/wheelchair/shower/toilet Needs Total Assistance Needs Some Assistance Needs No Assistance Please Describe the Assistance needed/providedPreparing meals Needs Total Assistance Needs Some Assistance Needs No Assistance Please Describe the Assistance needed/providedMaking medical appointments Needs Total Assistance Needs Some Assistance Needs No Assistance Please Describe the Assistance needed/providedShopping for groceries, taking medications Needs Total Assistance Needs Some Assistance Needs No Assistance Please Describe the Assistance needed/providedCompleting household chores Needs Total Assistance Needs Some Assistance Needs No Assistance Please Describe the Assistance needed/providedManaging money Needs Total Assistance Needs Some Assistance Needs No Assistance Please Describe the Assistance needed/providedApplicant’s ability to CommunicateIs 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 LearnIs 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 DirectionIs 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-SufficiencyIs 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?PhoneThis field is for validation purposes and should be left unchanged.
