*Activity Type Date (Assessment Date) *Activity Type *COS *COR *CFR *Legal Rep Status – Adult Legal Rep Name: Legal Rep Contact Info: (age 18 or older) *Dx Code: *Primary Diagnosis Name: *Dx Code: *Secondary Diagnosis Name: *Is there a history of a DD Dx? Y N If so, what is the dx? *Is there a history of a MI Dx? Y N If so, what is the dx? *Is there a history of a BI Dx? Y N If so, what is the dx? *Who was present at HRA? (more than one can be selected) 01 – Client 09 - NF staff 10 - 17 - Case manager 02 – Family Primary physician 11 - 18 - Legal counsel 03 - LTCC consultant Home care or community based 19 - Health plan coordinator 20 service provider – Ombudsman 21 04 - Social worker – RRS 22 - 05 - Public health nurse 12 – Advocate 13 Interpreter, English 23 - 06 - Hospital discharge - Conservator/Guardian 14 - Interpreter, ASL planner Consulting physician 15 - ICF/MR staff 16 - 98 – Other, please specify: 07 - Qualified mental Services for children with handicaps retardation professional 08 - Qualified mental health professional Screening & Assessment Information 1. *Reasons for Referral: 2. Current Living 3. *Current Housing Type: Situation: 5. Is member on a waiver? Yes No 4. *Assessment Team If so, what type? 6.*Dressing 7. *Grooming 8. *Bathing 9. *Eating 10. *Bed Mobility 11. *Transferring 12. *Walking 13. *Behavior
*Activity Type Date (Assessment Date) *Activity Type *COS *COR *CFR *Legal Rep Status – Adult (age 18 or older) Legal Rep Name: Legal Rep Contact Info: *Primary Diagnosis Name: *Dx Code: *Secondary Diagnosis Name: *Dx Code: *Is there a history of a DD Dx? Y N If so, what is the dx? *Is there a history of a MI Dx? Y N If so, what is the dx? *Is there a history of a BI Dx? Y N If so, what is the dx? *Who was present at HRA? (more than one can be selected) 01 – Client 02 – Family 03 - LTCC consultant 04 - Social worker 05 - Public health nurse 06 - Hospital discharge planner 07 - Qualified mental retardation professional 08 - Qualified mental health professional 09 - NF staff 10 - Primary physician 11 - Home care or community based service provider 12 – Advocate 13 - Conservator/Guardian 14 - Consulting physician 15 - ICF/MR staff 16 - Services for children with handicaps 17 - Case manager 18 - Legal counsel 19 - Health plan coordinator 20 – Ombudsman 21 – RRS 22 - Interpreter, English 23 - Interpreter, ASL 98 – Other, please specify: Screening & Assessment Information 1. *Reasons for Referral: 2. Current Living Situation: 3. *Current Housing Type: 4. *Assessment Team 5. Is member on a waiver? Yes No If so, what type? 6.*Dressing 7. *Grooming 8. *Bathing 9. *Eating 10. *Bed Mobility 11. *Transferring 12. *Walking 13. *Behavior