Deaf Bllind Medicaid Waiver Interest List Form Page 2

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PAGE 2 “Interest”
Please check the most correct statement regarding language.
___ Person is fluent in sign language and can socialize using language.
___ Person uses sign language and gestures to make their needs known.
___ Person has no formal language skills
___ Person has a different mode of communication. Please explain:
_________________________
List any medical conditions or infectious diseases, which will need special consideration:
___________________________________________________________________________
List medication(s) used: _______________________________________________________
Can the person take his/her own medicine: _____yes _____no
If NO, what assistance is needed to take the medication?
___________________________________________________________________________
Please check All applicable location(s) in which the person would desire to live:
_____ Austin
_____ Houston
_____ Midland
_____ Beaumont
_____ Laredo
_____ San Angelo
_____ Dallas/Fort Worth
_____ Longview
_____ San Antonio
_____ El Paso
_____ Lubbock
_____ Wichita Falls
The person would prefer to live in the following specific community:_______________________
Please check the appropriate status:
_____ The person is his/her own legal guardian.
_____ I am the legal guardian for the person. My name is:
_______________________________
_____ I am not the legal guardian for the person. The legal guardian's name is:
_______________________________
(I understand that this information will be used for referral purposes. The Texas Department of
Human Services, Texas Commission for the Blind, Texas School for the Blind and Visually
Impaired and Texas Department of Mental Health and Mental Retardation will share this
information. Statistical information may be shared with other agencies. I understand that I will
be contacted before any personal information from this form is shared with other parties).
______________________________
__________________
Parent/Guardian/Advocate
Date
Mail this form to:
Texas Department of Human Services
Or e-mail at:
Attention: Deaf-Blind Program Specialist
stephen.schoen@dhs.state.tx.us
P.O. Box 149030
fax- 512-438-5135
Austin, Texas 78714
Thank you for help in completing this survey.

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