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
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.
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.
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.
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.
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.
High Blood Pressure
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
To be used as a reference chart for the Suggested Medical History Outline, Section VII - Past Conditions.
Congenital Heart Defect
Pain/Pressure in Chest
High Blood Pressure
Low Blood Pressure
Dilating Gum Overgrowth
Chronic Skin Condition
Excessively Dry or Oily Skin
Diabetes (high blood sugar)
Hypoglycemia (low blood sugar)
Stomach or Intestinal Trouble
Trick Knee or Shoulder
Osteoporosis (loss of bone mass)
Otolaryngology (ear, nose)
Frequent Sore Throat
Cleft Lip, Palate Podiatry
Gall Bladder Condition Gynecological
Irregular Menstrual Period
Excessive Menstrual Flow
Sickle Cell Anemia
Abnormal Head Size
Frequent Severe Headache
Strabismus (crossed eyes)
Worry or Nervousness
Shortness of Breath
Chronic Lung Disease
Other Surgical Procedures
Name of Agency
Date History Written:
I. Identifying Data:
Name of Parent or Legal Guardian:
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?
VIII. Sources of Information
Signature of Person Preparing History Date
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
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
A.A.M.D. ABS (refer to manual)
Behavior Observations Checklists
BELOW I.Q. OF 40
SPECIAL: DEAF /or NON-VERBAL
L.I.P.S. Raven Progressive Matrices
Verbal subtests of Wechsler Scales
OTHERS (Which may be helpful for assessment
Adaptive Behavior Developmental Profile