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AGENCY OF HUMAN SERVICESCHILDREN’S PERSONAL CARE SERVICESVERMONT DEPARTMENT OF HEALTH108 CHERRY STREET; BOX 70BURLINGTON, VT 05401888.268.4860Instructions for completing Intake Form for use with Children’sPersonal Care Services Functional Ability Screening Tool Intake Form must be completed by an evaluator who has successfully completed training on both theIFS Intake Form and Children’s Personal Care Services Functional Ability Screening Tool (i.e., by anevaluator who is included in the Children’s Personal Care Services Assessor Directory) Intake Form can be completed with the family (in person, over the phone, or through collateralcontact). Demographic (or intake) portion of the IFS Intake Form can be completed directly by thefamily in advance. It is not appropriate for the family to complete non-demographic portions of theIntake Form directly nor is it appropriate for the family to complete any portion of the Children’sPersonal Care Services Functional Ability Screening Tool. The child (applicant) must be present—and participate—in the Children’s Personal Care Servicesapplication process. Applications where the child is not present or does not participate areconsidered incomplete and cannot be submitted for review. How the child participates may takedifferent forms depending on the child’s tolerance level for such activities. HOWEVER, it is importantto have an opportunity to for the assessor to interact with the child on some level. To apply for Children’s Personal Care Services, an Intake Form, Children’s Personal Care ServicesFunctional Ability Screen and Children’s Personal Care Services Care Plan must be completed.Please include supplemental information—such as Child Development Clinic report, psychologicalevaluation, Individualized Education Plan/Section 504 Plan, hospital/residential treatment facilitydischarge plans, physician notes. For new applicants, diagnosis verification must be included. Missing or incomplete information may result in delayed processing, returned application, or a denialof services. Please take care to provide complete and accurate information. Send completed materials to:Children’s Personal Care Servicesc/o Children with Special Health Needs108 Cherry Street, Box 70Burlington, VT 05401Fax: 802.863.6344Application Submission ChecklistBefore sending in a CPCS Application, have you included a completed:CPCS Intake FormCPCS Functional Assessment Screening ToolCPCS Care PlanRecent Supplemental Documents such as: IEP or 504 Plan, psychological evaluation, Well Child Notes from aphysician’s visit (completed within 3 years)FOR NEW APPLICATIONS ONLY: ICD-10 Coding/Diagnosis Verification Form completed by treating providerINTEGRATED FAMILY SERVICES INTAKE FORM
Applicant’s InitialsDate of Birth:Intake Date:A. Demographic Information1) Basic Information for whom services are being applied*First Name*Gender*Last NameUnique Identifier/Medicaid ID #Date of BirthAge Male Female Non-Binary*Physical Address*City*StateCounty*ZipMailing Address, if differentPrimary Diagnosis(including ICD-10)2) Assessor’s Name and Organization*Name and Organization*Intake Date*Mailing Address*Telephone Number*City*State*Zip3) Referral Source: (Check only one option) Self/family Legal Guardian Self Social Worker School/Preschool PICU/NICU Child Care Provider DCF—Family Services PhysicalTherapist, Occupational Therapist, or Speech LanguagePathologist Children’s Integrated Services (CIS) Team Primary/Specialty Care Provider Designated Developmental/Mental Health Agency or SpecializedServices Agency (please indicate) Children’s Personal Care Services Re-evaluation Notice Other (please specify):*Primary Concern/Reason for Referral:CPCS Intake FormVersion 2.2Page 2 of 24July 2018
Applicant’s InitialsDate of Birth:Intake Date:4)* Is the child in Department of Children and Family—Family Services (DCF) custody? If appropriate, DCF is aware of intake/referral? Yes NoIf yes, Department of Children and Family—Family Services Worker Contact Information5) Current Residence With Parent(s) Shared Physical Custody between Parents With Other Unpaid Family Member(s) With Legal Guardian Alone (includes person living alone receiving in-home services) DCF-Family Services Foster Care Shared Living Provider Homeless Hospice Care Facility ICF-DD Nursing Home—Rehabilitation Facility Nursing Home In-State Residential Treatment Facility Out-of-State Residential Treatment Facility Hospital Juvenile detention/jail With spouse/partner/roommate Other (pleasespecify):6a) *Parent/Guardian Contact Information (Primary Caregiver)(If both parents reside at same address, please complete jointly)*Relationship (check only one option): Foster Parent(s) Parent(s) (Biological) Shared Living Provider Parent(s) (Adopted – complete #9) Spouse/Partner Legal Guardian Other (please specify):*First Name*Last Name*AddressMailing Address, if different*City*State*Zip* Telephone Number(s)CPCS Intake FormVersion 2.2Page 3 of 24July 2018
Applicant’s InitialsDate of Birth:Intake Date:6b) Other Adult (Parent/Guardian) Contact Information (Secondary Caregiver)Relationship (check only one option): Foster Parent Parent (Biological) Shared Living Provider Parent (Adopted – complete #9) Other (please specify): Legal GuardianFirst NameLast NameAddressMailing Address, if differentCityStateZipTelephone Number(s)7) What is the family’s primary language? (check only one option) English Serbo-Croatian American Sign Language/TTY-Relay Service Other Arabic Somali(please specify): Burmese SpanishDoes the primary care giver have Limited English Dinka SwahiliProficiency? Yes No French RussianIs an interpreter is required? Yes No Napali Vietnamese8) Has this child been adopted?Is the family connected with postadoption services? No Yes, if yes, when? No Yes, if yes, what agency?(year) Is the child/family receiving post-adoption case management? If yes, please indicateorganization, case manager and contact number. Is the family receiving an adoption subsidy? Level of support?CPCS Intake FormVersion 2.2Page 4 of 24July 2018
Applicant’s InitialsDate of Birth:Intake Date:B. Household Information1) Family Composition (list all the people who currently live in your child’s home, excluding thechild)First and Last NameDate ofBirthGenderRelationship to oseList the parents and/or siblings who do not currently live in your child’s homeFirst and Last NameDate ofBirthGenderRelationship to ose2) Agency of Human Services IndicatorsDoes the family have:Safe, secure housing? No YesConcerns about the child(ren)’s safety No YesActive involvement in the criminal justice system? No YesCPCS Intake FormVersion 2.2Page 5 of 24July 2018
Applicant’s InitialsDate of Birth:Intake Date:Agency of Human Services Indicators (cont’d)Is the home environment free of abuse, neglectand/or exploitation?Is the parent interested in information regardingnutrition programs (WIC, 3-Squares, etc.)Is the parent interested in information relatedEconomic Services program (fuel assistance,ReachUp, etc.)Do(es) the parent(s)have a primaryphysicianDoes the parent haveany health concerns: No Yes No Yes No Yes No Yes No YesAdditional Information regarding AHS IndicatorsCPCS Intake FormVersion 2.2Page 6 of 24July 2018
Applicant’s InitialsDate of Birth:Intake Date:3) Narrative regarding family strengths, challenges, and resiliency factorsCPCS Intake FormVersion 2.2Page 7 of 24July 2018
Applicant’s InitialsDate of Birth:Intake Date:C. Health Information for the Child1) Private Insurance Information ( include policy number and clearly write numbers)Company Name & Policy NumberPolicy Holder’s NameIndividual NumberCompany Name & Policy NumberPolicy Holder’s NameIndividual Number2) List the hospitalizations, surgeries or medical procedures (i.e., MRI, CT Scan, EEG) within thelast 12-18 months (include supplemental materials as appropriate)DateLocation/ProviderReason for hospitalization or procedureHealth Care Provider Contact Information (add additional pages as needed)3) *Medical Home/Primary PhysicianDate of Last Visit:Date of Next Scheduled Visit:*Physician’s First Name*Physician’s Last Name*Address (including Group/Practice Name, if applicable)*CityCPCS Intake FormVersion 2.2*State*Zip*Telephone NumberPage 8 of 24July 2018
Applicant’s InitialsDate of Birth:3a) DentistDate of Last Visit:Intake Date:Date of Next Scheduled Visit:First NameLast NameAddress (including Group/Practice Name, if applicable)CityStateZipTelephone NumberSpecialty Provider (including complimentary/alternative provider)Date of Last Visit:Date of Next Scheduled Visit:Area of Specialization:First NameLast NameAddress (including Group/Practice Name, if applicable)CityStateZipTelephone NumberSpecialty Provider (including complimentary/alternative provider)Date of Last Visit:Date of Next Scheduled Visit:Area of SpecializationSpecialist’s First NameSpecialist’s Last NameAddress (including Group/Practice Name, if applicable)CityCPCS Intake FormVersion 2.2StateZipTelephone NumberPage 9 of 24July 2018
Applicant’s InitialsDate of Birth:Intake Date:Specialty Provider (including complimentary/alternative provider)Date of Last Visit:Date of Next Scheduled Visit:Area of SpecializationSpecialist’s First NameSpecialist’s Last NameAddress (including Group/Practice Name, if applicable)CityStateZipTelephone NumberDiagnostic Information4) Medical Problem List (each specialty service reserves the right to verify diagnosis, perspecific policy)If the child has been diagnosed with any medical, developmental or psychiatric conditions, please listbelow (include the diagnosing professional and date of diagnosis).CPCS Intake FormVersion 2.2Page 10 of 24July 2018
Applicant’s InitialsDate of Birth:Intake Date:D. Skilled Care Needs1) Health Care Needs Related to: Rehabilitationprogram for brain injury or coma (minimum of 15 hr/wk)Expected to last forat least 6 months Yes No Wound,site care or special skin care (please specify): One hour a day or less More than 1 hour/day Yes NoOSTOMY CARE Yes NoDIALYSIS (home vs. outpatient) Yes NoOXYGEN dependence and delivery (nasal cannula, CPAP, BiPAP, ventilator) Yes NoURINARY CATHETERIV ACCESSMEDICATION MANAGEMENTMust include current medication list and scheduleCPCS Intake FormVersion 2.2 Yes No Yes No Yes NoPage 11 of 24July 2018
Applicant’s InitialsDate of Birth:Intake Date:E. Emotional and Behavioral ChallengesPediatric Symptom Checklist-171) Does the child experience challenges with attention, such ty, unable to sit stillDaydreams too muchDistracted easilyHas trouble concentratingActs as if driven by a motor2) Does the child:Feel sad, unhappyFeel hopelessIs down on themselfWorry a lotSeem to be having less fun3) Does the child:Fight with othersNot listen to rulesNot understand other people’s feelingsTease othersBlame others for their troublesRefuse to shareTake things that do not belong to themNotes:CPCS Intake FormVersion 2.2Page 12 of 24July 2018
Applicant’s InitialsDate of Birth:Intake Date:F. Additional Health Information (add additional pages asneeded)Additional information related to the child’s recent health status (within the last 12-18 months),including any hospitalizations or rehabilitative placements. Please include previous screens orevaluations performed.CPCS Intake FormVersion 2.2Page 13 of 24July 2018
Applicant’s InitialsDate of Birth:Intake Date:G. Supports Information for the ChildPreviouslyReceivedCurrentlyReceivingHEALTH SERVICESPediatrician/Primary Care Physician (Medical Home Practice)Physical TherapyOccupational TherapySpeech/language TherapyHome Health ServicesNutrition SupportHearing SupportVision Support (Division for Blind and Visually Impaired Services)Communication SupportService Coordination/Case Management (please specify provider) Medical Home Children’s Mental Health/Developmental Services Home Health Agency Vermont Department of Health—Children with Special Health NeedsOther:Is the child actively enrolled in school (including private, alternative and home schooling)? Yes, if yes, what grade? NoSchool Name, City, StateSchool Case Manager’s Name ( or Teacher, if appropriate) and Telephone NumberIs child’s school attendance significantly affected (i.e., misses at least 50% of school, has analternate school day or has home tutoring) by their condition(s)? No Yes, if yes, please indicate howCPCS Intake FormVersion 2.2Page 14 of 24July 2018
Applicant’s InitialsDate of Birth:Intake Date:PreviouslyReceivedCurrentlyReceivingEDUCATION SERVICES(Agency of Education)Early Essential Education (EEE)Section 504 PlanIndividual Education Plan (IEP) (Special Education)Coordinated Services Plan (Act 264 Plan)IEP Transition PlanDivision of Voc. RehabilitationOther:OUT-OF-SCHOOL TIME SERVICES(School-age Children/youth)After School Services/TutorChild Care DCF Subsidized CDD- Accommodations GrantSummer and/or School Vacation CampsOther:CHILDREN’S INTEGRATED SERVICES-EARLY CHILDHOOD (CIS-EI)(Department for Children and Families)Children’s Integrated Services (ages 0-6)Child Care/Early Childhood Program/Pre-school DCF Subsidized CDD- Accommodations GrantEarly Head StartHead StartOther:CPCS Intake FormVersion 2.2Page 15 of 24July 2018
Applicant’s InitialsDate of Birth:Intake yReceivedCurrentlyReceivingCHILDREN WITH SPECIAL HEALTH NEEDS (Vermont Department of Health)Children with Special Health NeedsCare Coordinator/Contact: Respite (annual allocation): Child Development Clinic (Date): Cleft Palate Clinic Physiatry Clinic CF ClinicChildren’s Personal Care Services New Application Current Allocation/Level:High-Technology Home Care Level of Service Authorized:Pediatric Palliative Care Program (in conjunction with DVHA)Other:COMMUNITY MENTAL HEALTH AND/OR DEVELOPMENTAL DISABILITY SERVICESSUPPORTS(Department of Mental Health and Department of Disabilities, Aging andIndependent Living)School Based Clinician/Home-School CoordinationIndividual TherapyFamily TherapyGroup TherapyBehavioral Services/consultationAutism ServicesPsychiatric Services (Medication Management)Crisis ServicesCPCS Intake FormVersion 2.2Page 16 of 24July 2018
Applicant’s InitialsDate of Birth:Intake Date:COMMUNITY MENTAL HEALTH AND/OR DEVELOPMENTAL DISABILITY SERVICESSUPPORTS (cont’d)(Department of Mental Health and Department of Disabilities, Aging andIndependent ve Family Based ServicesTraumatic Brain Injury SupportsRespiteCommunity SupportsFlexible Family Funding: Waiting List Annual Level of Funding:Home ModificationsOther (please specify):Is there a need for assistance/support to access any of the above services? Either services the child iscurrently receiving or services the child might benefit from access to? If yes, please indicate whichservice(s)CPCS Intake FormVersion 2.2Page 17 of 24July 2018
Applicant’s InitialsH.Date of Birth:Intake Date:Description of Direct EvaluationProvide a brief description of your interaction/evaluation of this child for these supports. Pleaseprovide as much detail as possible related to your interaction and the child’s participation.CPCS Intake FormVersion 2.2Page 18 of 24July 2018
Applicant’s InitialsDate of Birth:Intake Date:I. Signature Page and Consent for Information SharingAssessor and Parent SignatureParent/Guardian:I acknowledge that the Children’s Personal Care Services application—including IntegratedFamily Services Intake, Functional Ability Screening Tool and Care Plan—was performedwith input provided by me and direct interaction with my child.Parent/Guardian SignatureDateAssessor:I acknowledge that I completed Children’s Personal Care Services application—includingIntegrated Family Services Intake, Functional Ability Screening Tool and Care Plan, withinput from the parent/guardian and direct interaction with the child.Assessor SignatureCPCS Intake FormVersion 2.2DatePage 19 of 24July 2018
Applicant’s InitialsDate of Birth:Intake Date:Consent for Information Sharing—within Agency of Human ServicesBy signing this form, I authorize and give my permission to allow disclosure:OF INFORMATION obtained by me in the course of applying for and/or receiving services orbenefits through the Agency of Human Services (AHS)FROM a staff person on an AHS department, divisionTO a staff person of another AHS department, divisionFOR THE PURPOSES OF:Determining eligibility for services or benefitsProviding services or benefits to the fullest extent and most efficient mannerEnsuring that services provided by AHS are coordinated and not duplicatedAvoiding repetitive and unnecessary paperworkYou do not have to sign this form. If you chose not to sign, any benefit to whichyou/your child is entitled will not be affected. However, by not giving authorization toshare information, you may not be able to participate in certain services to the fullestextent and as efficiently as possible.By signing the form, I understand:1) The reason(s) I am being asked to authorize the release of information2) That only information that is relevant to my application for or receipt of AHS services orbenefits shall be disclosed, and only to the minimum extent necessary to accomplish thepurposes identified above.3) That AHS departments and division may legally share most of the personal information theyhave about me on a need to know basis. However, state and federal laws do restrictsharing of certain types of information, absent my authorization.4) That I am authorizing AHS department and divisions to communication to disclose to oneanother personal information, when relevant, that otherwise could not be shared under stateand federal law as referenced above.5) While AHS takes every precaution to protect my health and other personal information, oneit is disclose pursuant to this authorization, it may be subject to re-disclosure.6) The re-disclosure of information concerning alcohol or drug abuse diagnosis, treatment orreferral for treatment and HIV status, without consent, is prohibited by law. By signing thisform, I authorize the initial disclosure of such information, if applicable, as well as anysubsequent disclosure among AHS departments and divisions.7) By checking the box below, I signify that I have not consented to the re-disclosure of suchinformation: I do not consent to re-disclosure of information concerning alcohol or drug abusediagnosis, treatment or referral for treatment and HIV status.8) I may revoke this authorization at any time by contacting: Children’s Personal CareServices at 800.660.4427, except to the extent that it has been acted upon.9) If I do not revoke or update the authorization, it will be in effect as long as I am receivingAHS services or benefits.CPCS Intake FormVersion 2.2Page 20 of 24July 2018
Applicant’s InitialsDate of Birth:Intake Date:10) I will be provided a copy of this informationIf you have questions about this form, please contact Children’s Personal CareServices by calling 800.660.4427.Signature of Individual or Parent/Legal RepresentativeDateRelationship to BeneficiarySignature of Assessor/Individual Explaining AuthorizationDateNameOrganizationCPCS Intake FormVersion 2.2Page 21 of 24July 2018
Applicant’s InitialsDate of Birth:Intake Date:Consent for Information Sharing—between AHS and Designated AgencyBy signing this form, I authorize and give my permission to allow disclosure:OF INFORMATION obtained by me in the course of applying for and/or receiving services orbenefits through the Agency of Human Services (AHS) or Designated Agency (DA)FROM an AHS staff personTO a staff person of a designated agencyFROM a staff person of a designated agencyTO an AHS staff personFOR THE PURPOSES OF:Determining eligibility for services or benefitsProviding services or benefits to the fullest extent and most efficient mannerEnsuring that services provided are coordinated and not duplicatedAvoiding repetitive and unnecessary paperworkYou do not have to sign this form. If you chose not to sign, any benefit to whichyou/your child is entitled will not be affected. However, by not giving authorization toshare information, you may not be able to participate in certain services to the fullestextent and as efficiently as possible.By signing the form, I understand:1) The reason(s) I am being asked to authorize the release of information2) That only information that is relevant to my application for or receipt of AHS or DA servicesor benefits shall be disclosed, and only to the minimum extent necessary to accomplish thepurposes identified above.3) That AHS and the DA may legally share most of the personal information they have aboutme on a need to know basis. However, state and federal laws do restrict sharing of certaintypes of information, absent my authorization.4) That I am authorizing AHS and the DA to communication to disclose to one anotherpersonal information, when relevant, that otherwise could not be shared under state andfederal law as referenced above.5) While AHS and the DA takes every precaution to protect my health and other personalinformation, one it is disclose pursuant to this authorization, it may be subject to redisclosure.6) The re-disclosure of information concerning alcohol or drug abuse diagnosis, treatment orreferral for treatment and HIV status, without consent, is prohibited by law. By signing thisform, I authorize the initial disclosure of such information, if applicable, as well as anysubsequent disclosure among AHS departments and divisions and the DA.7) By checking the box below, I signify that I have not consented to the re-disclosure of suchinformation:CPCS Intake FormVersion 2.2Page 22 of 24July 2018
Applicant’s InitialsDate of Birth:Intake Date: I do not consent to re-disclosure of information concerning alcohol or drug abusediagnosis, treatment or referral for treatment and HIV status.8) I may revoke this authorization at any time by contacting: Children’s Personal CareServices at 800.660.4427, except to the extent that it has been acted upon.9) If I do not revoke or update the authorization, it will be in effect as long as I am receivingservices or benefits.10) I will be provided a copy of this informationIf you have questions about this form, please contact Children’s Personal Care Servicesby calling 800.660.4427.Signature of Individual or Parent/Legal RepresentativeDateRelationship to BeneficiarySignature of Assessor/Individual Explaining AuthorizationDateNameOrganizationCPCS Intake FormVersion 2.2Page 23 of 24July 2018
Applicant’s InitialsDate of Birth:Intake Date:Consent for Information Sharing—between AHS and Health Care ProvidersI hereby authorize: All health care providers listed in this document The following providers:to disclose to the Vermont Department of Health, Children with Special Health Needs (CSHN)pertinent medical, educations, social or mental health records, X-rays, and/or screening reportsfor the purpose of determining medical necessity for Children’s Personal Care Servicesregarding this applicant.Eligibility for Children’s Personal Care Services is not conditioned upon my authorizing thisdisclosure. Further, I may revoke this authorization at any time except to the extent that CSHNhas already acted in reliance of it. In general, revocation must be submitted in writing and sentto CSHN/CPCS at this address:Vermont Department of Health/Children with Special Health Needs108 Cherry Street, Box 70Burlington, VT 05401Attn: Children’s Personal Care ServicesMeans of disclosure (check all that apply): written electronic oral audio tapeDate upon which this authorization will expire://is noted, expiration is three (3) years from the date it is signed.Signature of Individual or Parent/Legal GuardianPrinted Name(mm/dd/yyyy). If no dateDateRelationship to BeneficiaryWitness (age 18 or older):Signature and TitleDate:I hereby revoke this authorization on(date) atnot release any further information under this authorization.AM(time). DoSignature of Individual or Parent/Legal GuardianCPCS Intake FormVersion 2.2Page 24 of 24July 2018
of services. Please take care to provide complete and accurateinformation. Send completed materials to: Children's Personal Care Services c/o Children with Special Health Needs 108 Cherry Street, Box 70 . Burlington, VT 05401 . Fax: 802.863.6344 . bmission Checklist Before sending in a CPCS Application, have you included a completed: CPCS .
