Targeted Case Management Contact Monitoring Form Page 6
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Complete if Adult Family Home Services are on the PCSP:
N/A
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61. Are you related to your adult family home provider?
Yes
No
If yes, what is the relationship? ___________________________________________
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62. Do you receive a personal allowance?
Yes
No
If yes, how much? _____________________________________
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63. Are you included in activities in your home?
Yes
No If yes, in what way? _________________________________
64. What does your provider do to help you remain active in the community?
________________________________________________________________________________________________
_______________________________________________________________________________________________
65. Does your provider assist you with any of the following services?
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Bathing
Grooming
Enhancement of Skills
Care for Incontinence
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Dressing
Assistance with Eating
Transportation
66. How many participants live in your home? ___ ___________________________________
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Complete if Environmental Adaptation Services are on the PCSP:
N/A
67. What environmental adaptation services have been requested?
________________________________________________________________________________________________
________________________________________________________________________________________________
68. What environmental adaptation services have been completed?
________________________________________________________________________________________________
________________________________________________________________________________________________
69. Do you have any environmental adaptation needs? If yes, please explain.
________________________________________________________________________________________________
________________________________________________________________________________________________
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Complete if there are Additional Needs Identified Beyond Waiver Services:
N/A
(For example, additional needs include utility bills, pest control, transportation services, SNAP benefits, etc.)
Additional Needs Identified
____________________________
Source _______________
Additional Needs Identified
____________________________
Source _______________
Additional Needs Identified
____________________________
Source _______________
Additional Needs Identified
____________________________
Source _______________
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DMS-690 (1-1-16)
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Parent category: Business