Get Case Management Assessment Form

The Case Management Assessment form is a crucial tool used to gather comprehensive information about consumers seeking support services. This form helps assess an individual's needs and preferences, ensuring they receive the appropriate care tailored to their unique circumstances. If you or someone you know is in need of assistance, consider filling out the form by clicking the button below.

Structure

The Case Management Assessment form plays a crucial role in ensuring that individuals receive the appropriate support and services tailored to their unique needs. This comprehensive document gathers essential consumer information, including personal details such as name, address, and contact information, as well as demographic data like gender and income sources. It also addresses important aspects of a consumer's legal and medical history, allowing case managers to understand the full scope of each individual's situation. For those applying for Home- and Community-Based Services (HCBS), the form highlights the consumer's right to choose between HCBS and medical institutional services, ensuring informed decision-making. Furthermore, it captures vital information regarding court involvement, emergency contacts, and medical conditions, including diagnoses and treatment history. By compiling this information, the Case Management Assessment form serves as a foundational tool for case managers to develop effective care plans and coordinate services that promote the well-being and independence of consumers.

Case Management Assessment Preview

Case Management Comprehensive Assessment

Section A: Consumer Information

Consumer

Name: (First, M.I., Last)

Current Address:

Medicaid State ID#

Date Of Birth:

County of Residence:

Home Phone:

	County of Legal Settlement:

Work Phone:		Cell Phone:

E-mail:

Assessor

Name:

Agency:

Address:

Phone:

Signature

Title:

E-Mail:

Date

Type of Assessment
Initial
Annual
Special
Demographic Change Only				Date:
Discharge			Date:	Reason:
Basis of Case Management Eligibility
CMI	MR	DD	BI Waiver	Elderly Waiver

CMH Waiver

Habilitation

MFP

VERIFICATION OF HCBS WAIVER CONSUMER CHOICE: Complete this section for consumers applying for HCBS Brain Injury Waiver, Children’s Mental Health Waiver, Intellectual Disability Waiver.

Home- and Community-Based Services (HCBS)

My right to choose a Home- and Community-Based program has been explained to me. I have been advised that I may choose:

(1) Home- and Community-Based Services or (2) Medical Institutional Services.

I choose:	HCBS	Medical Institutional Services
Signature of Consumer or Guardian or Durable Power of Attorney for Health Care			Date

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:

Interdisciplinary team members consulted (including consumer):

Name

Title (if applicable)

Relationship to Consumer

Additional records reviewed:

Consumer Demographics

Gender:

Female

Male

Language:

Speaks English

Understands English

Needs interpreter services

Comments:

Yes

Monthly Income: (Please check all that apply)
Source	Amount
SSI	$
SSDI	$
Employment	$
Other (specify):	$
Comments:
Court Involvement:
Involuntary Commitment
Probation or Parole
Child in Need of Assistance (CINA)
Child Protection
Delinquency
Foster Care
Other (Identify)
None
Comments:

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:

Legal decision maker: (Please check all that apply)

None Guardian Attorney-in-fact Name: (First, M.I., Last)

Other (Specify):

Address:

Home Phone:

Work Phone:

Cell Phone:

E-mail:

Co-Decision Maker (if applicable):

Guardian Attorney-in-fact Name: (First, M.I., Last)

Other (Specify):

Address:

Home Phone:

Work Phone:

Cell Phone:

E-mail:

Financial Decision Maker: (e.g. Conservator or Attorney-in-fact)	No
Name: (First, M.I., Last)

Yes

(complete below)

Address:

Home Phone:			Work Phone:	Cell Phone:

E-mail:

Payee:	No	Yes (complete below)
Name: (First, M.I., Last)

Address:

Home Phone:			Work Phone:	Cell Phone:

E-mail:

Emergency Contacts:
Primary Contact
Name: (First, M.I., Last)				Relationship:

Address:

Home Phone:			Work Phone:	Cell Phone:

E-mail:

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:

Secondary Contact (if applicable):

Name: (First, M.I., Last)		Relationship:

Address:

Home Phone:	Work Phone:	Cell Phone:

E-mail:

Complete This Section For Adults (Age 18 and Over)

Veteran:

Yes

Marital Status:
Never Married
Married	Spouse’s Name:
Divorced

Legally Separated

Widowed

Unknown or Other – Specify

Comments:

Complete This Section For Children (Age 17 and Under)

With whom does the child live?

(If the child currently lives in a institutional setting, please make note in the comments section below.)

What are the child’s parent’s names?

Parents marital status:

Married

Divorced

Never married

If the parent’s are not living together, what is the non-custodial parent’s name and address? Name:

Street:

City, State, Zip:

Parent’s contact information (if different from the child’s):

Home Phone:

Work Phone:

Cell Phone:

E-Mail:

Are there siblings in the home?	Yes	No
Are any siblings receiving waiver services?		Yes	No

Are there any individuals who are not supposed to have contact with the child? If yes, specify:

Other Comments:

Yes

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:

Medical Information

Diagnoses:

Medical:

Diagnosis

Name and credential of professional making diagnosis:

Date of diagnosis:

Comments:

Mental Health (DSM-IV-TR)

Axis 1:

Axis 2:

Axis 3:

Axis 4:

Axis 5:

Name and credential of professional making diagnosis:	Date of diagnosis:

Comments:

Complete this section for consumers applying for or receiving HCBS Intellectual Disability Waiver.

List the most current IQ score, or if the IQ isn’t listed, give the consumer’s level of functioning within the range of mental retardation (mild, moderate, severe, profound):

IQ:

Range:

Date of Evaluation:

Complete this section for consumers applying for or receiving HCBS Brain Injury Waiver.

Diagnosis:

Date Injury Occurred:

Health Care Provider Information:

Who is your regular doctor?	None
Name		Address

Phone

Date of last visit (if known):

Reason:

Who is your regular dentist?

Name

None

Address

Phone

Date of last visit (if known):

Reason:

Are you seeing any other doctors, such as a psychiatrist, or specialists of any kind?

Yes (list below)

Don’t know

Name

Specialty

Address

Phone

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Section B: Medical and Physical Health

Health Conditions

B1. Overall, how would you rate your physical health?
Excellent	Good	Fair	Poor	No Response
Comments:

B2. Do you have any health problems that require assistance to manage?

Cardiac

Skin Related

G.I. Disorders

Urinary Tract

Weight problems

Evidence of communicable disease

Other – Specify

None

How do they affect you and how long have you had them?

Comments:

B3. Any respiratory problems that require assistance to manage?

Ventilator

Oxygen

Suctioning

Tracheotomy

Cardiorespiratory monitor

Chest physiotherapy

Nebulizer treatment

Other – Specify

None

How do they affect you and how long have you had them?

Comments:

B4. Do you regularly receive any of the following medical treatments?

Days per week

Hours per day

Nursing	no	yes
Physical Therapy	no	yes
Occupational Therapy	no	yes
Speech Therapy	no	yes
Supervision for Safety	no	yes
Diabetes Education	no	yes
Dialysis	no	yes
Respiratory Treatment	no	yes
Catheter Care	no	yes
Colostomy Care	no	yes
Nasogastric Tube Care	no	yes
Other	no	yes

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:

B5. Hearing

No hearing impairment.

Hearing impairment, but managed through assistive devices

Hearing difficulty at level of conversation.

Hears only very loud sounds.

No useful hearing.

Not determined.

Comments:

B6. Vision

Has no impairment of vision.

Vision impairment, but managed through assistive devices

Has difficulty seeing at level of print (far-sighted).

Has difficulty seeing obstacles in environment (near-sighted).

Has no useful vision.

Not determined.

Comments:

B7. Speech/Communication

Communicates independently or impairment has been compensated to function independently.

Communicates with difficulty but can be understood.

Communicates with sign language, symbol board, written messages, gestures or an interpreter.

Communicates inappropriate content, makes garbled sounds, or displays echolalia.

Does not communicate.

Comments:

B8. Sensory Perception (e.g. – taste, smell, tactile, spatial)

No impairment

Impaired – Specify

Comments:

B9. Cognitive Status

Alert and fully oriented

Alert and oriented with significant alteration on self-concept/mood

Generally oriented through use of assistive techniques

Cognitive deficits (e.g. orientation, attention/concentration, perception, memory, reasoning)

Exhibits mental status changes consistent with psychiatric disorder

Comatose, but responsive

Comatose, but unresponsive

Other – Specify

Comments:

B10. Musculoskelatal/Fine or Gross Motor Skills

No Impairment of Musculoskelatal/Fine or Gross Motor Skills
Impaired muscle tone
Contractures
Scoliosis
Paralysis:	Hemiplegia	Paraplegia	Quadriplegia	Other (Specify)

Comments:

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:

Complete This Section For Adults (Age 18 and Over)

	B11. Do you have someone who could stay with you for a while if you were sick or needed help?
		Yes (Complete below)	No
		Name:	Relationship:
		Address:
		City, State, Zip code:
		Phone:
	B12. Is there anybody you would not want to be involved with your care if you were sick or needed help?
		Yes (Complete below)	No
		Name:	Relationship:


			HEALTH CONDITIONS RISK FACTORS	YES	NO

	R1.	Has the consumer had a seizure in the past year?
	R2.	Does the consumer have a diagnosis of any other serious medical conditions or other serious health
		concerns (i.e., diabetes, cerebral palsy, heart condition, etc.)?
		If yes, list all conditions/concerns:
	R3.	Does the consumer have any life threatening allergies (such as peanuts, bee stings, or shellfish)?
	R4. Is the consumer in need of a primary health care provider (or the provider’s contact information is

		unknown)?
		unknown)?
	R5.	Is the consumer in need of a dentist (or dentist’s contact information is unknown)?
	R6. Is the consumer in need of a specialist (or the specialist’s contact information is unknown)?
	R7.	Has the consumer had difficulty making, keeping, or following through with appointments in the last year?

	R8.	In the past year, has the consumer gone to a hospital emergency room?
	R8.
		If yes, how many times?	Why?
		If yes, how many times?	Why?

	R9.	In the past year, has the consumer stayed overnight or longer in a hospital?
		If yes, how many times?	Why?
	R10. Is the consumer in need of someone to help if he or she was sick or injured?
Comment on any risk factors marked as “Yes” and address the issue in the Crisis Intervention Plan.				No. of risks:
Comments:

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:
Medication Use
B13. Are you currently taking any prescription medication?		Yes (complete below)		No
Medication Name	Dosage		Frequency		Purpose

Comments:

B14. Are you currently taking any over-the-counter medications on a regular basis (pain relievers, vitamins, laxatives, etc.)?

Yes (complete below) No

Medication Name

Dosage

Frequency

Purpose

Comments:

Form 470-4694 (Rev. 1/10)

Case Management Comprehensive Assessment

Consumer Name:

Complete this section only if the consumer is taking medications.

B15. Are any of your medications kept in a special place, like a locked container or the refrigerator?

Yes No Comments:

B16.	What pharmacy do you use?
B17.	How do you remember to take your medications? (Check all that apply.)
	By following directions	Calendar
	Caregiver gives them	Bubble wrap/Blister Pack
	Medpass Machine	Egg Carton, envelopes	Other:

Comments:

B18. How well do you self-administer medication?

With no help or supervision

With some help or occasional supervision

With a lot of help or constant supervision

Unable to administer own medications/caregiver gives them

Comments:

RN Set-up Pill Minder

MEDICATION ERROR RISK FACTORS

YES

3 = Frequently 2 = Sometimes 1 = Rarely 0 = Never

R11.

Has the consumer had problems with not taking or not receiving medications on time?

R12.

Has the consumer had problems with taking or being given the incorrect number of

medications?

R13. Has the consumer had problems with medications not being refilled on time?

R14. Have there been issues with medications not being re-evaluated timely?

R15.

Has the consumer had significant side effects from medications?

R16.

Has the consumer had significant medication changes in the past year?

R17.

Has the consumer refused or spit out medications?

R18.

Have there been problems with drug interactions?

R19. Has the consumer experienced health problems because of missing/refusing

medications?

R20.

Has the consumer misused prescription or over-the-counter medications (i.e., taken too

many at once)?

R21.

Has the consumer taken another person’s prescription medications?

R22.

Has the consumer used out-dated medications?

R23. Has the consumer used multiple pharmacies or multiple physicians in the past year?

Comment on any risk factors marked as “Yes” and address the issue in the Crisis

No. of risks:

Intervention Plan.

Comments:

Form 470-4694 (Rev. 1/10)

➤ PDF File

Document Data

Fact Name	Description
Purpose of the Form	The Case Management Comprehensive Assessment Form is designed to gather essential information about a consumer's needs and eligibility for various case management services.
Governing Law	This form is governed by state regulations related to Home- and Community-Based Services (HCBS) under Medicaid, which vary by state.
Consumer Rights	Consumers must be informed of their right to choose between Home- and Community-Based Services or Medical Institutional Services when applying for waivers.
Eligibility Criteria	The form assesses eligibility based on various criteria, including medical diagnoses, income sources, and legal decision-makers involved in the consumer's care.

How to Use Case Management Assessment

Completing the Case Management Assessment form is an essential step in ensuring that the necessary information is gathered for effective case management. After filling out this form, the next steps will involve reviewing the information provided and determining the appropriate services and support needed for the consumer.

Begin with Section A: Consumer Information. Fill in the consumer's name (First, M.I., Last) and current address.
Enter the Medicaid State ID number and the date of birth.
Provide the county of residence and legal settlement, along with home, work, and cell phone numbers.
Include the consumer's email address.
Next, fill in the assessor's name, title, agency, address, phone number, and email.
Sign and date the form, indicating the type of assessment (Initial, Annual, Special, or Demographic Change Only) and the discharge date if applicable.
For the basis of case management eligibility, select from the options provided (CMI, MR, DD, etc.).
In the Verification of HCBS Waiver Consumer Choice section, indicate the consumer's choice between Home- and Community-Based Services or Medical Institutional Services, and have the consumer or guardian sign and date this section.
List the interdisciplinary team members consulted, including their names, titles, and relationships to the consumer.
Document any additional records reviewed.
Fill in the consumer demographics, including gender, language proficiency, and need for interpreter services.
Provide details about the consumer's monthly income, checking all applicable sources and entering amounts.
Note any court involvement, specifying the type if applicable.
Identify the legal decision maker, checking all relevant options and providing their contact information.
If applicable, include information about a co-decision maker and financial decision maker, along with their contact details.
List emergency contacts, including primary and secondary contacts, with their names, relationships, and contact information.
For adults, indicate veteran status and marital status, including the spouse’s name if married.
For children, provide details about the child's living situation, parents' names, marital status, and any relevant comments.
In the medical information section, document any diagnoses along with the name and credential of the professional who made the diagnosis and the date of diagnosis.
Include any mental health diagnoses and the corresponding details.
If applicable, fill in the IQ score or level of functioning for consumers applying for the HCBS Intellectual Disability Waiver.
For consumers applying for the HCBS Brain Injury Waiver, include the diagnosis and date of injury.
Provide information about the consumer's regular healthcare providers, including doctors and dentists, along with the dates of last visits and reasons for those visits.
Finally, list any other doctors or specialists the consumer is seeing, if applicable.

Key Facts about Case Management Assessment

What is the purpose of the Case Management Assessment form?

The Case Management Assessment form is designed to gather essential information about consumers seeking case management services. It helps assess individual needs and eligibility for various Home- and Community-Based Services (HCBS) waivers. By collecting detailed consumer information, the form ensures that case managers can provide tailored support and resources to meet each person's unique circumstances.

Who should complete the Case Management Assessment form?

The form should be completed by the consumer or their authorized representative, such as a guardian or durable power of attorney for health care. It is important that the information provided is accurate and comprehensive. This ensures that the assessment reflects the consumer's needs and preferences. If the consumer is a child, a parent or guardian should fill out the form, providing necessary details about the child's living situation and family dynamics.

What information is required on the form?

The form requires various types of information, including personal details such as the consumer's name, address, and contact information. It also asks about demographic information, income sources, court involvement, medical history, and emergency contacts. Additionally, the form collects information about the consumer's preferences regarding Home- and Community-Based Services. Completing all sections of the form is crucial for a thorough assessment.

How is the information from the form used?

The information collected from the Case Management Assessment form is used to determine eligibility for case management services and specific waivers. It helps case managers create a personalized plan that addresses the consumer's needs. Furthermore, the data assists agencies in understanding the demographics and needs of the populations they serve, allowing for better resource allocation and service delivery.

Common mistakes

Filling out the Case Management Assessment form can be a straightforward process, but several common mistakes can lead to complications. One frequent error is failing to provide complete consumer information. All sections, including the consumer's name, address, and contact details, must be filled out accurately. Missing information can delay the assessment process and affect service delivery.

Another mistake is neglecting to indicate the type of assessment being conducted. The form requires a selection between initial, annual, special, or demographic change assessments. Not specifying this can lead to confusion about the purpose of the assessment and may impact the case management process.

Inaccuracies in the verification of Home- and Community-Based Services (HCBS) choice can also occur. Consumers must clearly indicate their choice between HCBS and medical institutional services. If this section is not completed correctly, it may hinder the consumer's access to preferred services.

People often overlook the importance of documenting income sources accurately. Each source of income, such as SSI or SSDI, should be checked and the amounts provided. Incomplete or incorrect income information can affect eligibility for various programs.

Additionally, individuals sometimes forget to include emergency contacts. This section is vital for ensuring that someone can be reached quickly in case of an emergency. Omitting this information may lead to delays in critical situations.

Another common oversight is not providing adequate details about the legal decision maker. If applicable, the names and contact information for guardians or attorneys-in-fact should be included. This information is crucial for legal and medical decisions regarding the consumer.

When it comes to medical information, people may fail to provide a complete list of diagnoses or the names of healthcare providers. This information is essential for understanding the consumer's health needs and ensuring appropriate care.

Furthermore, the section for children often sees incomplete information. Parents' names, marital status, and living arrangements should be clearly stated. Missing details about the child's living situation can complicate assessments and service provision.

Finally, many individuals do not review the entire form before submission. Taking the time to double-check all entries can help catch errors and ensure that the assessment process goes smoothly. Attention to detail is key in completing the Case Management Assessment form effectively.

Documents used along the form

The Case Management Assessment form is often accompanied by several other important documents that help provide a comprehensive view of a consumer's situation. Below is a list of related forms that are frequently used alongside the Case Management Assessment. Each document plays a specific role in the overall case management process.

Service Plan: This document outlines the specific services and supports a consumer will receive. It includes goals, timelines, and responsibilities of both the consumer and service providers.
Intake Form: This form collects initial information about the consumer, including their background, needs, and any immediate concerns. It serves as the starting point for case management.
Authorization for Release of Information: This form allows case managers to share the consumer's information with other relevant parties. It ensures that privacy laws are respected while facilitating communication.
Progress Notes: These notes document the ongoing interactions between the consumer and case manager. They track progress toward goals and any changes in the consumer's situation.
Eligibility Determination Form: This form assesses whether a consumer meets the criteria for specific programs or services. It helps determine the appropriate level of care needed.
Caregiver Assessment: This document evaluates the needs and capabilities of caregivers involved with the consumer. It identifies support services that may benefit the caregiver as well.
Incident Report: This form is used to document any significant incidents involving the consumer, such as accidents or behavioral issues. It is essential for ensuring safety and accountability.
Referral Form: This form is used when a consumer needs to be referred to additional services or specialists. It includes information about the reason for the referral and any relevant background.
Discharge Summary: This document summarizes the consumer's case upon discharge from services. It includes outcomes, recommendations for future care, and any follow-up plans.
Consumer Rights Statement: This form outlines the rights of consumers receiving services. It ensures they are aware of their rights regarding treatment, privacy, and participation in decision-making.

Each of these documents plays a vital role in ensuring that consumers receive appropriate and effective case management services. Together, they help create a comprehensive support system tailored to individual needs.

Similar forms

Intake Assessment Form: This document gathers initial information about a consumer’s needs and circumstances. Like the Case Management Assessment form, it includes personal details and identifies the services required by the consumer.
Service Plan: A Service Plan outlines the specific services a consumer will receive. Similar to the Case Management Assessment form, it considers the consumer’s preferences and needs, ensuring that the care provided aligns with their goals.
Eligibility Determination Form: This form assesses whether a consumer qualifies for specific programs or services. It shares a focus on consumer information and eligibility criteria, much like the Case Management Assessment form.
Client Progress Report: This document tracks the progress of a consumer over time. It is similar to the Case Management Assessment form in that it documents ongoing needs and changes in the consumer's situation.
Discharge Summary: A Discharge Summary provides a comprehensive overview when a consumer is leaving a program. Like the Case Management Assessment form, it includes important information about the consumer’s status and future recommendations.

Dos and Don'ts

Filling out the Case Management Assessment form accurately is crucial for ensuring that consumers receive the appropriate services and support. Here are some important dos and don’ts to keep in mind:

Do ensure that all personal information is complete and accurate, including the consumer’s name, address, and contact details.
Do provide clear and concise information about the consumer’s medical and mental health diagnoses.
Do check for any required signatures, especially from the consumer or their legal decision maker.
Do indicate the type of assessment being conducted, whether it is initial, annual, or special.

Don't leave any sections blank unless instructed to do so; incomplete forms can delay the assessment process.
Don't use jargon or abbreviations that may not be understood by all parties involved.
Don't forget to include information about emergency contacts, as this is essential for effective case management.
Don't submit the form without reviewing it for errors, as inaccuracies can lead to complications in service delivery.

Misconceptions

Understanding the Case Management Assessment form is crucial for consumers and their families. However, several misconceptions can lead to confusion. Below is a list of common misunderstandings about this important document.

The form is only for new consumers. Many believe that the Case Management Assessment form is only necessary for individuals seeking services for the first time. In reality, it is also required for annual assessments and any significant changes in a consumer's situation.
All information provided is shared publicly. Some individuals worry that the details they share on the form will be accessible to anyone. However, this information is kept confidential and is only shared with relevant professionals involved in the consumer's care.
The assessment is only about medical needs. While medical information is a part of the assessment, it also covers various aspects of a consumer's life, including social, emotional, and financial factors. A holistic view is essential for effective case management.
Completing the form guarantees services. It is a common misconception that filling out the assessment guarantees access to services. The form is a step in the process, but eligibility for services is determined based on specific criteria and availability.
Only the consumer needs to be involved. Some people think that the assessment only requires the consumer’s input. In fact, family members, guardians, and other support people can provide valuable insights and should be included in the process.

Addressing these misconceptions can help consumers and their families navigate the assessment process with greater confidence and understanding. It is important to approach this form as a tool for enhancing care and support.

Key takeaways

Filling out and using the Case Management Assessment form is essential for effective case management. Here are some key takeaways to consider:

Accurate Information: Ensure all consumer information is complete and accurate. This includes names, addresses, and contact details.
Eligibility Criteria: Clearly indicate the basis of case management eligibility. Familiarize yourself with the various waivers available.
Consumer Choice: Highlight the importance of consumer choice in selecting between Home- and Community-Based Services or Medical Institutional Services.
Interdisciplinary Team: Consult with interdisciplinary team members. Their insights can enhance the assessment process.
Legal Decision Makers: Identify and document the legal decision makers involved. This ensures clear communication and authority in decision-making.
Medical Information: Collect comprehensive medical information, including diagnoses and healthcare providers. This is crucial for understanding the consumer's needs.
Emergency Contacts: Include primary and secondary emergency contacts. This provides a safety net for the consumer in urgent situations.

By following these takeaways, you can ensure a thorough and effective assessment process that meets the needs of the consumer.