Family Support Program Date* Date Format: 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* Date Format: 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 clarifyDo you (the person applying for Family Support) receive any of the following?*Check all that applyAdoption AssistanceFood StampsResidential ServicesSocial Security IncomeSocial Security Disability IncomeFoster CareVocational RehabilitationNursing ServicesSupport LivingTN Early Intervention System (TEIS)PACE (Program of All-Inclusive Care for the Elderly)OPTIONS ProgramNoneWhat type of insurance do you (the person applying for Family Support) have*MedicaidTennCare (Medicaid)Private InsuranceTNCareUninsuredHave you (the person applying for Family Support) applied for or do you receive any of the following?*Check all that applyCHOICESECF CHOICESDIDD WaiversTBI GrantKatie Beckett ProgramAny In Home or Community SupportsNoneTo 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 Date Format: MM slash DD slash YYYY File Upload (encouraged)Accepted file types: doc, docx, pages, odt, rtf, tex, txt, wpd, wps, pdf.If someone other than the family/person is making a referralName of person making referral to Family Support First Last AgencyPhoneAddress 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?YesNoIf 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 AssistanceNeeds Some AssistanceNeeds No AssistancePlease Describe the Assistance needed/providedDressingNeeds Total AssistanceNeeds Some AssistanceNeeds No AssistancePlease Describe the Assistance needed/providedBathingNeeds Total AssistanceNeeds Some AssistanceNeeds No AssistancePlease Describe the Assistance needed/providedToiletingNeeds Total AssistanceNeeds Some AssistanceNeeds No AssistancePlease Describe the Assistance needed/providedTransfers in/out of bed/wheelchair/shower/toiletNeeds Total AssistanceNeeds Some AssistanceNeeds No AssistancePlease Describe the Assistance needed/providedPreparing mealsNeeds Total AssistanceNeeds Some AssistanceNeeds No AssistancePlease Describe the Assistance needed/providedMaking medical appointmentsNeeds Total AssistanceNeeds Some AssistanceNeeds No AssistancePlease Describe the Assistance needed/providedShopping for groceries, taking medicationsNeeds Total AssistanceNeeds Some AssistanceNeeds No AssistancePlease Describe the Assistance needed/providedCompleting household choresNeeds Total AssistanceNeeds Some AssistanceNeeds No AssistancePlease Describe the Assistance needed/providedManaging moneyNeeds Total AssistanceNeeds Some AssistanceNeeds No AssistancePlease Describe the Assistance needed/providedApplicant’s ability to CommunicateIs the applicant’s ability to communicate affected by their disability?YesNoHow 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?YesNoApplicant’s ability to LearnIs the applicant’s ability to learn affected by their disability?YesNoIf 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?YesNoIf YES, how is his/her mobility affected?Does the applicant require a supportive device (walker, cane, wheelchair, etc.)?YesNoIf 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)?YesNoDoes the applicant have behavioral or stemming issues?YesNoIs the applicant able to tell and manage time?YesNoHow does the applicant’s disability affect his/her judgement and ability to make decisions?Does the applicant need constant supervision due to safety concerns?YesNoApplicant’s Economic Self-SufficiencyIs the applicant employed?YesNoAre accommodations made so that he/she can work (altered schedule, escort, etc.)YesNoIf YES, please describe those accommodations:How does the applicant’s disability affect his/her ability to work?CommentsThis field is for validation purposes and should be left unchanged.
