Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-20817A (Rev. 07/2008)

STATE OF WISCONSIN Completion of this form is required by Section 49.77(3s), Wis. Stats.

ASSESSMENT WORKSHEET FOR NATURAL RESIDENTIAL SETTING
FOR INDIVIDUALS WITH SERIOUS AND PERSISTENT MENTAL ILLNESS AND/OR ALCOHOL AND OTHER DRUG DEPENDENT DIAGNOSES
Name ­ SSI Recipient (Last, First, MI)

For an individual who has not been found eligible using F-20817, complete a comprehensive assessment that meets, at a minimum, COP or WMAP Targeted Case Management criteria. Following assessment, enter the approximate number of hours per month needed in each service area.

1. 2. 3.

Case planning, monitoring and review Case management Assessment / diagnosis Assistance in obtaining needed benefits (e.g., financial support, legal services, money management) Advocacy Education, support, and consultation to clients' families and other major supports Supportive counseling/psychotherapy Assertive outreach Symptom management Medical support/obtaining health care Referral Socialization and interpersonal Assistance with and training in community functioning (e.g., family relationships, parenting)

14. 15.

Transportation Assistance in learning and/or completing daily living tasks (e.g., personal grooming, laundry, planning/preparing food, purchasing necessities, housekeeping, financial management, training in the use of available transportation) Crisis intervention Vocational Services Acquiring/maintaining adequate housing Social/recreational activities Coordination of services with other human service programs On-site supervision needed to protect health, safety, welfare Respite to family or other major supports Other--Specify:

4.

16. 17. 18. 19. 20. 21. 22. 23.

5. 6. 7. 8. 9. 10. 11. 12. 13.

TOTAL Monthly Hours

IF THE TOTAL HOURS ARE 40 HOURS OR MORE OF 'NEEDS' PER MONTH, THE PERSON IS ELIGIBLE FOR SSI-E.

Keep in agency case file