PMF 4.1.3 Cenpatico Integrated Care
Transitioning to Adulthood Checklist
Member Name:
DOB:
CIS ID:
/ /
AHCCCS ID:
16th
The tasks outlined on this form should begin as soon as the child reaches his/her
birthday and should be reviewed at CFT/ART meetings each
month until the youth turns 18 years of age. Youth should be co-facilitating CFT meetings and initiating completion of this checklist as appropriate.
Begin Date:
/ /
DCS Involved?
Yes
No
Natural supports (list names):
Community supports (list):
Please ensure that the following tasks are completed no later than 6 months after the youth’s 16th birthday:
1.
Casey Life Skills Assessment has been completed with the member. If not, date CLSA is scheduled:
/ /
Upon completion of CLSA assessment:
2. Casey Life Skills Assessment has been reviewed with the member, and needed services and supports are listed in service plan.
Yes
No
Yes
No
Please review the following at each CFT meeting. At this time, the member chooses to:
Remain with current BH team
Transfer to adult team within agency
Transfer to another ICCA
Close from all services
Complete the following section ONLY if youth decides to transfer to an adult team within agency OR another ICCA:
1.
Current DRC/RC identifies an adult DRC/RC.
2.
Current DRC/RC invites the adult team DRC/RC to CFT meetings (at age 17.5).
Yes
Yes
No
No
N/A
Referrals and resources:
1.
The DRC/RC ensures the member is aware of the following resources and refers the member, as appropriate:
Education assistance (IEP, continued education, etc.)
Housing Services
Social Security/Disability benefits
SMI Eligibility Determination (if applicable)
Transportation Services
2.
Referral to Vocational Rehabilitation/employment services has been made.
Yes
No
N/A
3.
The CFT identifies a need for Special Assistance or guardianship for the member, as appropriate.
Yes
No
N/A
a.
Yes
No
N/A
The youth has a qualifying SMI diagnosis.
Yes
No
a.
Yes
No
N/A
Yes
No
N/A
Yes
No
Referrals for housing or housing resources have been made, as needed.
Yes
No
N/A
The DRC/RC or other support assists the member and/or team to obtain copies of:
Yes
No
N/A
4.
5.
6.
If yes, the DRC/RC ensures all necessary documentation is completed and submitted no later than
17.5 years of age.
The DRC/RC assists the member in completing the AHCCCS application process.
The DRC/RC assists the member in securing safe and stable housing upon the member’s
a.
7.
If yes, the DRC/RC works to gather necessary information no later than 17.5 years of age.
18th
birthday.
Arizona State Identification card or Driver’s License
An original social security card
Education records (IEP, transcripts, etc.)
Medical (including immunization records) and psychiatric records.
An original or certified copy of his or her birth certificate.
C-IC PM Form 10.6.1, Transition Checklist
Last Revised:
Effective Date:
PMF 4.1.3 Cenpatico Integrated Care
Transitioning to Adulthood Checklist
Review this checklist, monthly at CFT/ART meetings to ensure that all areas are appropriately and completely addressed upon
member turning 18 years old.
Member (Sign at FIRST completion)
/
Name (print)
Signature
/
Date
(Dedicated) Recovery Coach
/
Name (print)
Title
Signature
/
Date
Please enter date of each checklist review:
/
/
Member Initials:
/
/
Member
Initials:
Date of Review:
Date of Review:
/
/
Member Initials:
/
/
Member
Initials:
Date of Review:
Date of Review:
/
/
Member Initials:
/
/
Member
Initials:
Date of Review:
Date of Review:
/
/
Member Initials:
/
/
Member
Initials:
Date of Review:
Date of Review:
/
/
Member Initials:
/
/
Member
Initials:
Date of Review:
Date of Review:
Member (Sign at FINAL completion)
/
Name (print)
Signature
/
Date
(Dedicated) Recovery Coach
/
Name (print)
Title
Signature
/
Date
C-IC PM Form 10.6.1, Transition Checklist
Last Revised:
Effective Date: