Intake and Screening

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Brain Injury Association of VT Intake Interview Guide

Source: Brain Injury Association of VT
This guide was developed by Neuro-Resource Facilitators (NRFs) at the BIAVT to use with persons with brain injury. NRFs function similarly to Options Counselors. It has been modified for potential use by Vermont ADRC Partner Agencies providing Options Counseling.
(Word)
(PDF)
Associated Date: April 2011

MD OC Intake Form

Source: Maryland
This Options Counseling form was developed by Maryland. It is available as a document, as web enabled automated versions, and even through mobile devices. The automated versions are currently mock-ups for the pilot phase.
(External Link) Caption: mobile version • File type: web
(PDF)
Associated Date: January 2012

ADRC Intake Assessment Recommendations Report

Source: Nevada
This report examines two I&R Tool software programs to determine which would be most useful and effective for documenting intake data in Nevada.
(PDF)
Associated Date: August 2011

NV ADRC Intake Form

Source: Nevada
Nevada Care Connection (ADRC) uses this detailed form to collect information about new consumers such as demographics, current services, assistance needs with activities of daily living, and finances.
(PDF)
Associated Date: October 2011

Florida complete-screening example

Source: Florida
This form is for a screening based on Florida's Medicaid and public assistance programs. Answer categories (instead of open-ended answers) make it easier to complete. By entering this client information into its Information and Referral (I&R) software application, the ADRC is able to share the client's responses among the agency staff assisting clients with Medicaid benefits, SNAP (Supplemental Nutrition Assistance Program, formerly Food Stamps), SHINE (Florida's State Health Insurance Program), and the Low Income Subsidy (LIS).

The answers are verified by staff as applications are completed throughout the process and the data can be updated with changes/additions when necessary. This streamlines the application process for the client since each staff member does not have to ask for the information to be repeated. The data collected are also available to the I&R Helpline and Intake staff allowing them to see what transpired, which helps them better serve the client on any subsequent calls.

(PDF)
Associated Date: May 31, 2011

Bangor's Intake Procedures

Source: Eastern Agency on Aging, ME
In order to accurately record and collect information from people who call for information and assistance, Eastern Agency on Aging Intake and Referral staff has a standard list of questions that are asked. This policy is developed to ensure that the information is consistent and applicable to the services requested.
(Word)
(PDF)
Added May 27, 2010

Brown County Wisconsin Options Counseling Assessment

Source: Brown County, Wisconsin ADRC
This assessment form is completed by options counselors at the Brown County Wisconsin ADRC when they conduct home visits for options counseling.
(Word)
(PDF)
Added May 19, 2010

ADSSP Toolkits Resources for Individuals and Families

Source: ADSSP National Resource Center Studies
Toolkit describes how state officials can provide accurate information and streamlined access to dementia capable services to individuals and families.
(PDF)
Updated December 28, 2010

Arkansas Targeting Residents for Transition into the Community

Source: Greg Arling, Pete Castelluccio, Robert Kane, Julie Bershadsky
Arkansas is currently engaged in efforts to transition and divert persons from nursing home admission. This study, prepared for the state, provides information that can be used in targeting individuals for successful transitions from nursing home to community and was utilized in CLP implementation.
(Word)
(PDF)
Associated Date: May 2008

West Virginia Pre-Screening Tool

Source: West Virginia
West Virginia developed this pre-screening tool to help ADRC staff pre-screen consumers for eligibility for home and community based services programs.
(Word)
(PDF)
Added July 16, 2009

Lubbock County Pre- and Post-ADRC Consumer Flow

Source: Lubbock County, Texas ADRC
The ADRC in Lubbock County, Texas, submitted these flow charts of how consumers interacted with the agency both before and after implementation of the ADRC.
(Word)
(PDF)
Added June 29, 2009

Harris County Pre- and Post-ADRC Consumer Flow

Source: Harris County, Texas ADRC
The ADRC in Harris County, Texas, submitted this description of how consumers interacted with the agency both before and after implementation of the ADRC.
(Word)
(PDF)
Added June 29, 2009

NY Connects - Pre-Screening Tool

Source: New York
This tool is used as a pre-screen by NY Connects staff to identify potential consumers for the NHDMP
(Word)
(PDF)
Added May 17, 2009

New York NHD Screening Tool

Source: New York
New York state provides this example of an NHD screening tool.
(PDF)
Added April 20, 2009

Arkansas NHD Consumer Registration Form

Source: Arkansas
Arkansas uses this form to register NHD consumers. It seeks basic personal, demographic and health information.
(PDF)
Updated February 10, 2009

Arkansas NHD Assessment Tool

Source: Arkansas
Arkansas developed this tool to assess consumers' eligibility for the Nursing Home Diversion Program. It asks for information on basic demographics, financial and insurance status, and current health status.
(Word)
(PDF)
Updated February 10, 2009

West Virginia NHD Screening Application

Source: West Virginia
West Virginia developed this form to determine NHD consumer eligibility for the program. It asks for caregiver and care receiver demographic information.
(Word)
(PDF)
Updated February 10, 2009

West Virginia NHD Care Receiver Assessment

Source: West Virginia
West Virginia uses this form to assess and document the health of the person receiving NHD care. It asks for information regarding advanced directives and current health status.
(Word)
(PDF)
Updated February 10, 2009

Minnesota NHD Proxy Rapid Screen

Source: Minnesota
This document from Minnesota is an example of screening questions to ask NHD consumers seeking services.
(PDF)
Updated February 10, 2009

West Virginia Intake Form

Source: West Virginia
West Virginia provided this example of the Intake form that is used by their ADRC network.
(Word)
(PDF)
Updated July 16, 2009

Arizona Common Intake Form and Instructions

Source: Arizona ADRC
This form originated through a collaborative process by Arizona's ADRC partners to create a common intake form which would assess for program eligibility. It was developed through examination of common intake information collected by the following entities: SHIP; ALTCS (Medicaid agency); DDD; AAAs, Centers for Independent Living, and Benefits Check-up.
(PDF)
(PDF)
Updated September 8, 2008

Ohio ADRN Intake and Referral Form

Source: Ohio ADRN
The Ohio ADRN Intake Form and Referral Form is used to capture an array of basic consumer/client information.
(Word)
(PDF)
Added June 16, 2008

Kentucky Resource Market Client Intake Form

Source: Northern Kentucky Resource Market
This intake form is used for ADRC clients by the Kentucky Resource Market.
(Word)
(PDF)
Associated Date: June 05, 2008

North Carolina Screening Tool

Source: North Carolina
This screening tool is used by the ADRC in Forsyth County, North Carolina. Training around this tool has provided an opportunity for collaboration across partner agencies.
(PDF)
Associated Date: February 14, 2008

Ohio Intake and Referral Form

Source: Ohio Aging and Disability Resource Network
Ohio has provided this example of the Intake and Referral form that is used by their Aging and Disability Resource Network.
(Word)
(PDF)
Added February 4, 2008

Kansas Expedited Service Delivery Worksheet

Source: Kansas ADRC
This expedited service delivery one-page worksheet is used by the aging network in Kansas to facilitate in-home services beginning before Medicaid determination. It includes 13 questions that assess a person's financial status. Answers to the questions generate an assumption about whether a person will qualify for Medicaid or not. If it looks like someone will be eligible, Medicaid waiver services may begin. If they are eventually deemed ineligible, the state legislature has set aside a $200,000 fund to cover the costs of the services provided.
(Word)
(PDF)
Updated January 16, 2008

NJ Office of Community Options Screening Tool
Source: New Jersey ADRC
This document is the actual form used in hospitals to screen patients at risk of nursing home placement, developed by the New Jersey Office of Community Choice Options.
(Word)
Updated December 11, 2007

New Jersey "At Risk for Nursing Facility Placement" Criteria

Source: New Jersey
This document gives the at-risk criteria for nursing facility placement of the New Jersey Division of Aging and Community Services.
(Word)
Updated April 15, 2008

New Jersey Hospital At-Risk Criteria Pre-admission Screening - Streamlining Call Presentation - November 9, 2006

Source: New Jersey ADRC
New Jersey presented about their Hospital At-Risk Criteria Pre-admission Screening Pilot on the November 9, 2006 Streamlining Access Peer Workgroup call.
(Powerpoint)
Associated Date: November 09, 2006

New Jersey ADRC Automated Screen for Community Services

Source: New Jersey ADRC
This automated screening tool consists of clinical/functional as well as financial questions that New Jersey ADRCs ask consumers over the phone. Consumer responses trigger 5 levels of care 1) Information & Assistance 2) Homemaker 3) Intermittent Personal Care 4) Home Care and 5) Nursing Facility. Based upon the results a home visit may be arranged. Included are screen shots of the MIS Consumer Record and Contact Record
(Word)
(PDF)
Updated February 10, 2009

Bangor ADRC Intake and Referral Policy

Source: Bangor ADRC, Maine
A core service provided by the Community Services Department of Eastern AAA and ADRC is information and assistance to seniors and adults with disabilities. This policy helps to outline the intake and referral process guidelines to be used by staff, paid or volunteer, to ensure consistency and completeness of the referral and assistance process.
(Word)
(PDF)
Associated Date: December 20, 2010

Bangor ADRC Standard Intake Questions

Source: Bangor ADRC, Maine
In order to accurately record and collect information from people who call for information and assistance, Eastern AAA and ADRC Intake and Referral staff has a standard list of questions that are asked. This policy is developed to ensure that the information is consistent and applicable to the services requested.
(Word)
(PDF)
Associated Date: December 20, 2010

Florida Department of Elder Affairs Prioritization Assessment Form

Source: Florida
This document, also called the 701A, is used statewide in Florida, not specifically for the ADRC initiative. Florida is in the process of developing a new Eligibility Screen instrument for testing by the ADRCs, which will be an expanded version of the current 701A, and will collect additional information to streamline the eligibility determination referral process for those appearing to be eligible for public assistance programs, such as Medicaid and Food Stamps. The new instrument is being designed in the format of a script to be completed electronically through interview between a trained ADRC professional and the applicant. Until the new Eligibility Screen is implemented, the 701A will continue to be used in the three ADRC pilot sites.
(Word)
(PDF)
Updated December 11, 2007

New York DRAFT Universal Intake Form for Disaster
Source: New York
In the wake of Hurricane Katrina, New York developed a draft 'Universal Intake for Disaster' instrument to streamline access during disasters. ADRCs may find this tool useful as they plan for future disaster response activities.
(PDF)
(Word)
Updated December 11, 2007

Minnesota Developmental Disabilities Screening Document
Source: Minnesota
The Minnesota ADRC utilizes this screen to assess the long term care needs of individuals with developmental disabilities.
(External Link)
Updated November 20, 2007

Minnesota Long Term Care Screening Document
Source: Minnesota
The Minnesota ADRC utilizes this screen to assess consumer long term care needs.
(External Link)
Updated November 20, 2007

Pennsylvania ADRC Screening Tool

Source: Pennsylvania
This tool was developed by an ADRC subcommittee and can be used to determine probable functional and financial eligibility for programs under the auspices of the ADRCs. This tool can also be used as a basis for both information and referral and the counseling process.
(Excel)
(PDF)
Updated February 10, 2009

ServiceLink RC Referral Check-off Form for Hospital Discharge Planners

Source: New Hampshire
This document is a check-off form for the use of hospital discharge planners in determining whether an individual should be referred to the Resource Center.
(PDF)
(Word)
Updated December 11, 2007

MA Protocols for Common Intake and Consultation Form

Source: Massachusetts
Protocols used by the Massachusetts ADRC pilot sites when it is determined that a consumer's needs would be best met by follow-up from a partner agency. Includes instructions for use of Consultation Form (posted on this website under ADRC Service Components/ Case Management).
(PDF)
(Word)
Updated February 10, 2009

MA Common Intake and Consultation Form

Source: Massachusetts
Form used by the two Massachusetts ADRC aging and disability parters to refer consumers to a partner agency, or to request the other pilot site to follow up with a new consumer.
(PDF)
(Word)
Updated February 10, 2009

Intake Tools Matrix

Source: The Lewin Group & AoA, ADRC-TAE
Overview of selected intake forms used by aging and other human service agencies. Contains descriptions of informational elements, format, targeted populations and staff training.
(Excel)
(PDF)
Updated June 11, 2010

Screening and Referral Tools Matrix

Source: The Lewin Group & AoA, ADRC-TAE
Overview of selected screening and referral tools used by aging and other human service agencies. Contains descriptions of informational elements, format, targeted populations and staff training.
(PDF)
(Excel)
Updated February 10, 2009

FAQ: Uniformity for Intake and Assessment Forms
Source: AoA-CMS
If more than one organization is conducting intake and eligibility for the ADRC, are they required to use the same forms?
(Internal Link)
Updated February 10, 2009

CO Intake and Screening Form

Source: Colorado
This provides examples of the screening and tools used in Colorado.
(External Link)
Updated November 20, 2007

La Crosse County Care Management Enrollment Request form

Source: La Crosse Co., Wisconsin
This is an example of an enrollment request form used by the Care Management Organization in La Crosse County, WI.
(PDF)
Updated November 20, 2007