CPSA PM Form 10.6.1
Transitioning to Adulthood Checklist
If you have trouble reading this notice because the letters are too small or the words are hard to read, please
call CPSA at (800) 771-9889 option 2 or (520) 318-6946 and someone will help you. This form is available in
other languages and formats if you need it.
Si usted tiene problemas leyendo ésta carta por que las letras son muy pequeñas o las palabras son difíciles
de leer, por favor llame a nuestras oficinas al (800) 771-9889 opción 2 o al (520) 318-6946 y alquien le
ayudará. Esta carta está disponible en otros idiomas y formatos si es que lo necesita.
Member Name:
DOB:
/
/
CIS ID:
AHCCCS ID:
The tasks outlined on this form should begin near the time of the child's 17 th birthday and be completed about the
time the child completes his or her transition to adulthood.
Begin Date:
/
/
Professional supports:
Natural supports:
The following tasks are completed when the member is transitioning from a children's services provider to an adult
services provider.
1. The member completes a new Ansell Casey Life Skills Assessment (between ages 17 & 17.5).
Yes
No
2. The case manager reviews the Ansell Casey Life Skills Assessment with the member to ensure the
member understands how to address areas of need.
Yes
No
3. The case manager discusses with the member the option to stay with the current CSP until reaching the
age of 22, to transfer to an adult CSP, or to leave the behavioral health system entirely.
Yes
No
At this time, the member chooses to:
Remain with children’s CSP
Transfer to adult CSP
Leave the behavioral health care system
The following should occur if the member decides to transfer to an adult CSP
a. The case manager identifies an adult CSP liaison.
Yes
No
b. The case manager invites the adult CSP liaison to CFT meetings.
Yes
No
c.
Yes
No
d. The children's CSP liaison attends at least one ART meeting following transfer to adult services.
Yes
No
e. The children's and adult's CSP liaison ensures all necessary documentation was transferred.
Yes
No
The adult CSP liaison meets with the CFT at least once prior to the transfer date..
The following tasks are completed whether the member is transitioning from a children's to an adult provider or
entering the system of care between the ages of 18-22 at an adult CSP.
1. The case manager ensures the member is aware of the following resource and refers the member, as appropriate:
Education (IEPs, continued educ., etc.)
Employment/Job Training
Housing Services
Life Skills/Money Management Training
Peer /Social Supports
Transportation Services
2. The case manager makes a referral to Vocational Rebabilitation.
Yes
No
N/A
3. The case manager makes a referral to Employment Services.
Yes
No
N/A
CPSA PM Form 10.6.1, Transition Checklist
Last Revised: 10/15/2012
Effective Date: 04/15/2015
CPSA PM Form 10.6.1
Transitioning to Adulthood Checklist
Member Name:
DOB:
CIS ID:
AHCCCS ID:
/
/
4. The CFT/ART refers the member for an SMI evaluation, as appropriate.
Yes
No
If yes, does the member have a qualifying SMI diagnosis as decribed in PM Section 3.10, SMI
Eligibility Determination?
Yes
No
If yes, the case manager ensures all necessary documentation is completed and submited no
later than 30 days prior to the child’s 18th birthday or upon opening an episode of care.
Yes
No
Yes
No
5. The case manager assists the member in completing the AHCCCS application process.
N/A
N/A
18th
The AHCCCS application must be completed at least 45 days prior to the member's
birthday, or 45
days prior to the member's 19th birthday, if the member is covered under KidsCare. Enter date upon which
the application was completed (Include confirmation page from the Health-e Arizona in the record.)
/
/
6. The member chooses to:
Remain in his or her current living arrangement
Change to a new living arrangement.
If the member chooses to change to a new living arrangement, identify:
7. The case manager assists the member with identifying a significant, non-professional adult/natural support
willing to provide on-going support and guidance as the child transitions into adulthood.
Yes
No
8. The case manager assists the member to obtain copies of:
a. Educational records.
Yes
No
N/A
b. Medical (including immunization records) and psychiatric records.
Yes
No
N/A
c.
Yes
No
N/A
d. A replacement social security card.
Yes
No
N/A
e. An Arizona identification card or driver’s license.
Yes
No
N/A
An original or certified copy of his or her birth certificate.
The following tasks are completed by the adult services provider after the member transitions from the children's
provider or upon opening an episode of care if the member enters the system of care as an adult.
1. The adult CSP provides the member with an orientation to the services offered by the provider.
Yes
No
2. The ART updates the ISP and crisis plan.
Yes
No
Review this checklist at every CFT/ART to ensure that all areas are appropriately and completely addressed.
Date of Completion:
/
/
Member:
/
Name (print):
Signature
/
Date
Case Manager
/
Name (print):
Title:
Signature
/
Date
CFT/ART Facilitator
/
Name (print):
Title:
Signature
/
Date
CPSA PM Form 10.6.1, Transition Checklist
Last Revised: 10/15/2012
Effective Date: 04/15/2015