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HOME & COMMUNITY-BASED SUPPORT OF TENNESSEE
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REFERRAL FORM
Person in Need of Service
Last Name:
First Name:
Gender:
Male
Female
Date of birth:
January 2021
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Current Address:
Street Name
Street No.
City
State
Zip Code
Phone No.
Service Needed:
(Check all that apply)
Behavioral
Supported Living
Nursing
Day Services
Current Agency:
(If any)
Phone No.:
Reason for Referral (check all that apply)
Skill Deficits
Independent Living Skills
Communication Skills
Academic Skills
Self-Care Skills
Working Skills
Social Skills
Other
Challenging Behaviors
Physical Aggression
Verbal Aggression
Non-Compliance
Pica
Property Destruction
Inappropriate Sexual Behavior
Refusal of Medical Attention
Severe Behavior Outbursts
Self-Injurious Behavior
Other
Subjective Assessment Of Risk And Need For Services In The Last 90 Days
Challenging
Behaviors
Description
Are any challenging behaviors life-threatening?
Yes
No
Do any challenging behaviors provide a health risk to the person?
Yes
No
Do any challenging behaviors interfere with learning?
Yes
No
Will any behaviors become serious in the near future if not treated?
Yes
No
Are any challenging behaviors dangerous to others?
Yes
No
Are any challenging behaviors of great concern to caregivers?
Yes
No
Are any challenging behaviors getting worse or not improving?
Yes
No
Has this been a problem for some time?
Yes
No
Do any challenging behaviors damage materials?
Yes
No
Do any challenging behaviors interfere with community acceptance?
Yes
No
Are psychotropic drugs used to control any challenging behavior?
Yes
No
Have any challenging behaviors resulted in police/court involvement?
Yes
No
Do any challenging behaviors interfere with the person's Quality of Life?
Yes
No
Would other positive behaviors improve if any of the challenging ones improved?
Yes
No
Did any challenging behaviors require medical/nurse attention in the last 90 days?
Yes
No
Did any challenging behavior result in property damage in the last 90 days?
Yes
No
Do any challenging behaviors require the use of protective equipment/restraint?
Yes
No
Do any challenging behaviors interrupt the individual's daily routine?
Yes
No
Legal Guardian's Name & No.:
Independent Support Coordinator & Agency:
Person Completing This Form:
Realtionship to indivdual:
Contact Information
Your email address:
Phone Number: