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Intermediate Care Facilities for the Intellectually Disabled –(ICF/ID)– for children and adults are licensed by the DBHDS Office of Licensing, then a provider must be certified by the Virginia Department of Health, Office of Licensing and Certification, whose contact information may be found at the following link: http://www.vdh.virginia.gov/OLC/longtermcare/. 

• Admission – Discharge Protocols to Training Centers (2011 Revision)
• Amended Regulations for Respite and Emergency Care Admissions to Mental Retardation Facilities
• Regulations Establishing Procedures for the Voluntary Admission of Individuals Who Are Mentally Retarded to State Mental Retardation Facilities
• Supports for Living Booklet: 3221eID  (Word) 

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Following is a list of Virginia Person Centered Planning (PCP) Process forms for use by providers of care for persons who reside in Intermediate Care Facilities for the Intellectually Disabled (ICF/ID).

1. Important To-For Worksheet  (Word) (pdf)
2. Essential Information Long form  (Word) (pdf)
3. Essential Information - Chart Filing Order  (Word) (pdf)
4. Part II Profile IV - VA ISP Blank  (Word) (pdf)
5. Part V Plan for Supports  (Word) (pdf)
6. Discussion Record Blank  (Word) (pdf)
7. Communication Plan II  (Word) (pdf)
8. Personal Schedule Blank  (Word) (pdf)
9. Revised QMRP Review  (Word) (pdf)
10. ISP Change Note  (Word) (pdf)
11. ISP Checklist - data  (xls) (pdf)

• The SIS^® Additional Support Needs Risk Assessment
• Related Forms and Resources:
  • ICF/ID Private and CSB Forms for Admission

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• AMC Referral form for Training Centers: 1168eID  (Word)
• Emergency and Respite Application  (DBHDS #3223eID – 2011 Revision)

• AMC Referral form for Training Centers: 1168eID  (Word)
• Regular (Judicial Certification) Admission Forms for Training Centers
• Admission – Discharge Protocols to Training Centers  (DMAS 121 – 2011 Revision)

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Some of the following links will go to forms that reside on the DMAS Web site.
DMAS forms 119, 121 and 121 A, please email Susan directly for instructions (email listed below)

• Level of Functioning Survey (Word)

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If you have any questions about the Intermediate Care Facilities for the Intellectually Disabled (ICF/ID), please contact:

Susan A. Elmore
Facilities and Community Resource Manager
Office of Developmental Services
Dept. of Behavioral Health and Developmental Services (DBHDS)
P.O. Box 1797
1220 Bank Street
Richmond, Va. 23218-1797

Email: Susan.Elmore@dbhds.virginia.gov

Office Phone: 804-371-2478

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• Contact
• Forms:
  • Admission Forms for Training Centers
  • ICF/ID Forms for PCP
  • ICF/ID Private and CSB forms for Admission
• Regulations

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