INSTRUCTIONS FOR COMPLETING THE
STATEWIDE APPLICATION FOR TRAINING CENTER SERVICES
I. COMPLETE REFERRAL PACKAGE
Each
application for admission to a state mental retardation facility must be
prescreened by the appropriate community services board and have all the
documentation necessary for the facility to determine the applicant’s
eligibility for services. A complete referral package must contain the
following items:
A. Medical History and current status
B. Psychological functioning level
C. Social History and current status
D. Educational needs and current
Individualized Education Plan (for school-aged children) or vocational or
training needs (for adults)
E. Completed Application for Services Forms
·
Identifying Information (DMH 885E 1146A)
·
Family Information (DMH 885E 1146B)
·
Current Medical Condition (DMH 885E 1146C)
·
Immunization History (DMH 885E 1146D)
·
Medication History (DMH 885E 1166)
·
Service History (DMH 885E 1167)
·
Services Requested (DMH 885E 1168)
·
Skills and Behaviors Checklist (DMH 885E 1147)
·
Level of Functioning Survey (DMH 885E 1157)
·
Documentation of Recipient Choice (DMH 885E
1149)
·
MR Prescreening Report (DMH 885E 0231)
F. A completed
Pre-discharge Plan outlining the services to be provided upon discharge and the
anticipated date of discharge.
Following
the receipt of the complete referral package, the facility must notify the
community services board (CSB) of the determination of the applicant’s
eligibility within thirty working days.
II. GENERAL INSTRUCTIONS
All the above listed forms, assessments and reports
are to be completed for each application for regular admission.
A
request for either respite care or emergency admission does not require
submission of service history, medication history or services request forms.
For more information, please see the Regulations for Respite and Emergency Care
Admissions to Mental Retardation Facilities.
Because
of the specific services available at some training centers such as skilled
nursing facilities, or limited medical services, additional information may be
requested. At the time of a regular
admission, the field Reimbursement Office will request financial information from the
applicant or the applicant’s family, guardian or legally authorized
representative. The financial information
will not be shared with the facility staff.
III. APPLICATION FOR SERVICES FORMS
A. Identifying Information/Family
Information (DMH 885E 1146A and DMH 885E1146B)
The case manager
assisting in the admission process should complete these forms. The case
manager may already have the information necessary to complete the forms in the
case management records.
B. Skills and Behaviors Check List (DMH 855E 1147)
This booklet is used as
a means of obtaining specific data regarding the applicant’s level of
functioning. It is anticipated that a completed application may contain more
than one booklet. For example, a child attending a public school program may
behave much differently when at home. In that case it would be important to
have the teacher and the parents provide data separately.
C. Suggested
Medical History Outline and Current Medical Condition (DMH 885E 1146C)
Many of the persons
referred to state facilities for mental retardation require intensive medical
monitoring and follow-up. It is therefore very important for the facility to
receive as much medical information as possible. The medical sections of the
application require a complete medical history, information from both past records as well as a description
of the applicant’s current condition.
Occasionally, an
applicant will have recently had a thorough evaluation by medical staff in a
special diagnostic setting. In that case the medical history information may be
available in the case manager’s files and it will not be necessary to rewrite
it. The Current Medical Condition form (DMH 885E 1146C)
will still be required as an update to the existing history.
When there is no
medical history readily available, the case manager must gather data from all
possible sources to complete the medical history outline. This information may
come from parents or other family members, other agency files or from the
applicant’s primary physician. If the case manager cannot obtain all the
necessary information due to a lack of records or the unavailability of family
members, the case manager should send the facility all the historical data that
is available and should complete the Current Medical Condition form.
D. Service History and Medication
History (DMH 885E
1167 and DMH 885E 1166)
These forms should be
self-explanatory. It should be noted that these forms are not necessary if the
application is for a respite care or emergency admission.
E. Services Requested (DMH 885E 1168)
This section should be
self-explanatory. It should be noted that this section is not necessary if the
application is for a respite care or emergency admission.
F. Suggested
Social History Outline and Suggested
Psychological Evaluation Outline (see attached)
This outline is
provided to give the case manager examples of reports, which will fulfill the
requirements for a completed referral package.
It is anticipated that
the case manager will already have a social history and a psychological
evaluation report in the case management record. If the existing reports are
not as complete as the outline requests, the facility may require additional
data. If no current reports are available, the case manager will be requested
to obtain them.
G. Immunization History (DMH
885E 1146D)
Facility staff should indicate
whether this form should be sent with the other application
forms or submitted the actual
time of admission.
H. MR Pre-Screening Report (DMH 876E 231)
This document is
required for all admission requests and should be self-explanatory.
SUGGESTED MEDICAL HISTORY OUTLINE
To be used in
conjunction with other reports during the application process for admission to
a state mental retardation facility.
I. Applicant Identification: Name,
Date of Birth, Address, and Telephone Number, Name of Parent or Legally
Authorized Representative
II.
Pre-Natal History: List any complications during the pregnancy
and any significant medical factors, which may have a bearing on the
applicant’s current condition. Did the mother take any medications or drink
heavily during the pregnancy? Was the applicant’s birth early, on time or late?
Did the mother experience high blood pressure, vaginal bleeding, German
measles, or other unusual conditions? Was there an RH factor problem? Did the
pregnancy progress normally?
III. Birth and New Born History:
Describe the applicant’s birth by indicating the type of delivery (vaginal,
breech, Cesarean), length of labor, anesthesia used, birth weight, APGAR
Scores, head size and any unusual conditions present during the birth process.
Indicate whether the applicant was born in a hospital or at home. Give the name
of the hospital and attending physician, if available. If the applicant’s
diagnosis was made at this time, give all the relevant data.
IV. Childhood: Describe any medical
conditions the applicant experienced during applicant’s childhood especially
those which may have some bearing on applicant’s current condition or need for
future treatment. Describe the period in which the applicant was first
suspected to have mental retardation and the procedure used to make this
determination. Describe the onset of any behavioral, neurological, orthopedic,
seizure, respiratory, cardiac, digestive, mobility, visual, speech or hearing
disorder. If the applicant received a complete diagnostic evaluation at a major
medical facility, attach the results of that evaluation. Indicate the general
health of the applicant during childhood, including childhood diseases.
V.
Developmental History: Describe the applicant’s skill
development. When did applicant learn to roll over, sit up, stand, walk, eat
with a spoon, speak single words, use the toilet, dress, etc.? Was applicant
shy or afraid of people? Did the applicant spend a great deal of time doing
repetitive things like spinning toys, waving his hands or rocking? Did
applicant seem to prefer those activities to contacts with other people? When
did applicant begin to enjoy the company of other people and does he still get
along with others?
VI. Diagnosis: State the applicant’s
past and current medical diagnoses for any medical or surgical conditions known
to be present or part of the applicant’s history. Include all relevant
conditions such as seizure disorder or physical impairment. State the level of
the applicant’s mental retardation and the age at which this was first
determined. Indicate who first made the diagnosis known to the applicant’s
family. Has anyone else in the applicant’s family ever been given the same
diagnosis?
VII.
Past Conditions: Using the attached
chart as a reference, list all conditions, which the applicant has experienced
and give additional information as appropriate. Concentrate especially on those
conditions, which are of a recurring nature or those, which resulted in a
permanent disability. Give the type and date of any surgical operations the
applicant has had.
VIII. Hospitalizations: For each hospitalization list the name and
address of the hospital, the name and address of the primary physician, the
reason for and date of the hospitalization, and the course of treatment. Attach
copies of all available discharge summaries.
IX.
Menstrual and Reproductive History: Describe the applicant’s
birth control method (sterilization, medication or other). If the applicant is
female describe her menstrual cycle. Are her periods regular? Does she have
obvious mood swings related to her period? Does she experience cramps or
unusual bleeding? Has she ever been pregnant? If so, give details.
Family
Medical History: Using the following list for reference, note any
conditions, which have been experienced by the applicant’s extended family.
Include brothers, sisters, mother, father, grandparents, cousins, and aunts or
uncles who are related by blood. Indicate the condition and the member(s) of
the family experiencing it.
Diabetes
|
Tuberculosis
|
Seizures
|
Mental Retardation
|
Cerebral Palsy
|
Mental Illness
|
Heart Disease
|
High Blood Pressure
|
Kidney Disease
|
Cancer
|
Parkinson's
|
Alzheimer’s
|
X.
Other Conditions: List any other current medical conditions that
have not already been addressed.
XI.
Recommendations: List recommendations for the care of the
applicant that have been made by health care professionals.
XII.
Sources of Information: List sources of information used to
complete this Medical History Outline.
______________________________________ ___________________________
Signature of Person Preparing History Date
PAST CONDITIONS
To be used as a reference chart
for the Suggested
Medical History Outline, Section VII - Past Conditions.
Allergy
Food
Drug
Hay Fever
Asthma
Cardiovascular
Congenital Heart Defect
Heart Palpitations
Heart Murmur
Heart Attack
Pain/Pressure in Chest
High Blood Pressure
Low Blood Pressure
Varicose Veins
Edema
Stroke
Childhood Diseases
German Measles
Measles
Whooping Cough
Scarlet Fever
Rheumatic Fever
Chicken Pox
Mumps
Frequent Colds
Dental
Dilating Gum Overgrowth
Dentures
Gum Disease
Tooth Extraction
Numerous Cavities
Dermatology
Chronic Skin Condition
Deceits Ulcer
Excessively Dry or Oily Skin
Dandruff
Acne
Fungal Infection
Herpes Virus
Endocrinology
Thyroid Disorder
Diabetes (high blood sugar)
Hypoglycemia (low blood sugar)
Gastroenterology/Urology
Ulcer
Appendicitis
Hernia
Stomach or Intestinal Trouble
Hemorrhoids
Orthopedic
Back Problems
Trick Knee or Shoulder
Skeletal Deformity
Broken Bones
Osteoporosis (loss of bone mass)
Arthritis
Bursitis
Gout
Otolaryngology (ear, nose)
Ear Infection
Frequent Sore Throat
Strep Throat
Sinusitis
Frequent Colds
Hearing Difficulties
Tonsillitis
Cleft Lip, Palate Podiatry
Foot Deformity
Bunions
Plantar Warts
Fungal Infections
Ingrown Toenails
|
Chronic Constipation
Frequent Diarrhea
Parasites
Kidney/Bladder Infection
Frequent Urination
Venereal Disease
Gall Bladder Condition Gynecological
Irregular Menstrual Period
Excessive Menstrual Flow
Severe Cramps
Venereal Disease
Hematology
Anemia
Sickle Cell Anemia
Hepatitis
Injuries/Accidents
Poisoning
Broken Bones
Sprains
Head Injury
Severe Lacerations
Joint Injury
Cramps
Spasms
Weakness
Torn Muscles
Paralysis
Polio
Neurological
Seizure Disorder
Cerebral Palsy
Paralysis
Meningitis
Encephalitis
Brain Damage
Abnormal Head Size
Frequent Severe Headache
Oncology
Cancer
Premalignant Condition
Tumor
Cyst
Ophthalmology
Strabismus (crossed eyes)
Cataract
Glaucoma
Vision Difficulties
Psychiatric/Emotional
Frequent Anxiety
Frequent Depression
Worry or Nervousness
Alcoholism
Substance Abuse
Psychosis
Neurosis
Insomnia
Eating Disorders
Pulmonary
Shortness of Breath
Pneumonia
Chronic Lung Disease
Emphysema
Chronic Cough
Bronchitis
Tuberculosis
Surgery
Appendectomy
Tonsillectomy
Tubal Ligation
Hysterectomy
Vasectomy
Colostomy
Other Surgical Procedures
|
SUGGESTED SOCIAL HISTORY OUTLINE
Name
of Agency
Address
Date History Written:
Birth Date:
I. Identifying
Data:
Name:
Address:
Name
of Parent or Legal Guardian:
Address:
Telephone #:
II. Reason for Referral: When and how
did the applicant become known to the referring agency? Why is residential care
being requested? And why is it being requested now?
III. Present Status:
A. Skill Level: Describe the applicant’s current abilities
in the areas of personal care and hygiene, survival skills, leisure time
skills, time concepts, money management, etc. Be as specific as you can be in
describing the amount of supervision or assistance needed.
B. Socialization: Describe the
applicant’s way of relating to family members, peers, and authority figures.
How does the applicant respond in group situations? Does the applicant tend to
be sociable or withdrawn? How does the applicant express or indicate moods of
happiness, sadness and anger?
C. Behavior: Does the applicant show
hyperactivity, destructiveness, aggression or other behaviors, which are
difficult to manage? If so, describe the intensity and frequency of the
behavior. What seems to bring on this behavior and what helps to stop it?
Please list any effective resources.
IV. Personal History:
A. Developmental Milestones: Note the
age of the applicant when he first learned to roll over, smile, sit up, stand,
walk, talk, feed self and toilet unassisted.
B. History of the Problem and Treatment:
Relate information as to when, why and by whom the developmental delays were
first noted. If the developmental delay has been attributed to an accident or
trauma, describe the incident. Summarize all significant evaluations,
hospitalizations and program enrollments.
C. History of Care: If the applicant
has lived in settings other than his/her family’s home, review those placements
being sure to include information as to why the placement was arranged, the
type of care provided and reasons why the placement was terminated. Information
as to the applicant’s adjustment to new living situations would also be
helpful.
D. Vocational History: If the
applicant has been employed, include information regarding the types of work
involved and job performance.
E. Marital History: If the applicant
has been married, include name of spouse, date of marriage, date of separation
or divorce, and current marital status.
F. Financial Resources: Describe
financial benefits the applicant receives; include all resources in addition to
public assistance programs. If the applicant has a special burial fund, provide
details.
V. Family History:
A. Father: Give name, age, educational
level, and information regarding physical and emotional health. Indicate any
special interests and abilities. Describe his attitude toward and relationship
with the applicant.
B. Mother: Give same information as
for father.
C. Siblings: List in order of birth
from oldest to youngest, including same information as for parents.
D. Others Living in the Home: Give
name, relationship to family, age, and any relevant information regarding
physical and emotional health. How long has he/she lived with the applicant’s
family and how long will he/she remain there? Describe his/her attitude toward
and manner of relating to the applicant.
E. Living Situation: Describe the
family’s socio-economic status, emotional climate and any relevant family
issues of significance.
VI. Diagnostic Impressions: What do you
feel are the major issues for the applicant and his family at this time? What
improvement do you feel can be made without removing the applicant from the
current living situation. What services would be needed to accomplish this?
What do you feel the applicant and family would gain from admission to a
residential care setting?
VII. Recommendations
VIII. Sources of Information
__________________________________ ___________________________
Signature of Person Preparing History
Date
SUGGESTED
PSYCHOLOGICAL EVALUATION OUTLINE
This outline is to be used in conjunction with
other reports to determine eligibility for admission to a state mental
retardation facility. It is to include a summarization of all previous
psychological testing, when this information is available. In addition, the
individual’s current (one year or less) levels of intellectual and adaptive
functioning are to be given. It is not necessary to complete this outline if a
current report is available which addresses ALL of the information requested.
I. Identifying
Data: Indicate the applicant’s name, date of birth, date of the evaluation,
name of the examiner, and the agency providing the testing service.
II. Reason
for Referral:
III. Standardized
Psychological Testing Performed to Date: List the names of all tests used,
forms of tests, date tests were administered, scores, and results including
functional levels.
IV. Current
Intellectual Classification: Using the 1983 AAFID Classification in Mental
Retardation manual and the standard deviation of the test administered,
indicate the level of the applicant’s mental retardation (mild, moderate,
severe or profound).
V. Current
Adaptive Behavior Level: Refer to the 1983 AAMD Classification in Mental
Retardation manual for additional information. List the applicant’s level of
adaptive behavior as determined by the AAMD ABS or other standardized
assessment tool.
VI. Test
Behavior and/or Observations: Describe the applicant’s positive qualities
and behaviors. Also describe maladaptive or inappropriate behaviors, being sure
to include information regarding frequency and intensity. Include information
regarding intervention programs implemented and results.
VII.
Summary and Recommendations:
_______________________________ __________________
Signature of
Examiner Date
Suggested tests
to be used for assessment are as follows:
INTELLIGENCE
(I.Q. 40 and above)
WAIS—R, WAIS, WISC—R, WISC
WPPSI, S-B, SIT, CIII
|
ADAPTIVE
BEHAVIOR
A.A.M.D.
ABS (refer to manual)
Behavior Observations
Checklists
|
BELOW
I.Q. OF 40
PPVT, ALPERN-BOLL
DEVELOPMENTAL
PROFILE, SIT, CIIT, C.M.M.S
|
SPECIAL: DEAF /or NON-VERBAL
L.I.P.S. Raven Progressive
Matrices
|
SPECIAL:
BLIND
OHWAKI KOHS
Verbal subtests of Wechsler
Scales
|
OTHERS
(Which may be helpful for assessment
V.S.M.S.
Adaptive
Behavior Developmental Profile
Fairview Scales
Denver
|