Flex Care/Flex Care Plus/Flex-Care Plus-Extended (Co.)
Supportive Housing Treatment Application
Overview
Using this assessment tool helps the clinical team, member and others involved in the member’s care
determine what level of housing support is needed to ensure the member’s recovery goals are being met.
Supportive housing services identified and accessed through this application are designed to be short
term. Supported Housing is a service for individuals determined to have a Serious Mental Illness, which
helps them find and stay in independent, safe housing. Supported Housing services include a range of
services based on identified need that help the person remain in housing and avoid eviction. Title XIX/XXI
eligible and Non‑Title XIX/XXI persons determined to have an SMI diagnosis receiving housing services
may be asked to help pay for the cost of room and board.
The clinical team’s role is to provide the member with a range of available services and answer questions.
Once the form is completed, place it in the member’s clinical record in the “Assessment” section;
Document any services identified and agreed upon to help support the member in the individual service
plan (ISP).
Directions
When completing this application, the clinical team will discuss and evaluate the member on their ability
and confidence in completing a variety of tasks related to daily living/independent living skills and
activities. All questions must be answered and all parties must sign the assessment. Information to
answer each of the questions may be obtained through input from the member, family members,
guardians, clinical team, peer mentors, family mentors or other involved service providers. Remember,
areas of need identified are to be incorporated into the person’s individual service plan (ISP) with
observable, measurable and attainable change.
At the end of the assessment in the Summary you can select the appropriate level of
care which you as a clinical team have determined best fits the individual needs of
the recipient.
Please email the completed assessment to Mercy Maricopa Housing department
at: flexcare@mercymaricopa.org
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Name:
CIS# :
DOB:
SSN#:
MEMBER INFORMATION
Gender: Choose an item.
Title 19: Choose an item.
Race/Ethnicity:
Member’s preferred language:
ESL☐ Interpreter☐ Sign Language☐ Limited English Proficiency☐ Translation☐
Diagnosis:
PNO: Choose an item.
CM:
CM email:
CC:
CC email:
CD:
CD email:
Level of CM services: Choose an item.
CLINICAL TEAM INFORMATION
Clinic: Choose an item. Phone:
FINANCIAL AND LEGAL
Does the member have monthly income?: Choose an item. If yes, total amount:
Does the member have a photo ID?: Choose an item.
If no, when will they receive an ID?:
Does the member have a social security card?: Choose an item.
If no, when will they receive their card?:
What is the member’s citizen status? :
Type of legal documentation:
Does the member have a payee?: Yes☐ No ☐
If yes, name and contact information:
Member Legal Information:(check all applicable options) Probation ☐ Parole☐ COE☐
COT☐
NGRI☐
GEI☐
Guardian☐
Is the member currently in jail?: Choose an item. If yes, is release contingent upon residential placement?:
Use to research state of AZ possible criminal history:
http://apps.supremecourt.az.gov/publicaccess/caselookup.aspx?AspxAutoDetectCookieSupport=1
Sex Offender: Choose an item. Level:
Sex Offender Type:
Felony: Choose an item.
If Yes, what charge(s) and when?:
Misdemeanor: Choose an item. If yes, list charge(s) and when?:
MEDICAL HEALTH PLAN INFORMATION
Medical Health Plan Type:
Medical Health Plan ID#:
Contact name:
Phone #:
OTHER PERTINENT INFORMATION
Can the member return to a primary residence?: Choose an item.
If no, why:
Is the member homeless?: Choose an item. Has the member ever been homeless?: Choose an item.
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Current living status:
Currently inpatient: Choose an item. If yes, where?:
ACT Team: Choose an item. Does the member meet criteria?: Yes ☐ No ☐
If yes – have they been referred and when?:
Does the member require DDD services?: Choose an item.
SUBSTANCE USE/ABUSE
History of substance abuse?: Choose an item. Date of last use:
Length of substance use history:
yes, primary drug of choice:
If
List Substance Abuse Treatment Hx (please include dates & types including outp. and resi. treatment)
Type of service:
Date:
Type of service:
Date:
Type of service:
Date:
Free from intoxication of withdrawal risk: Choose an item. How long:
MEDICAL
Are there any medical impairments?: Choose an item. If yes (please check all options that apply)
Diabetes☐ MRSA☐ Dementia☐ Alzheimer☐ TBI ☐ Medication interaction☐ Morbidly Obese☐
High Blood Pressure☐ Ambulation☐ COPD☐ Other☐
Member needs review for ALTCS?: Status of ALTCS application:
Are there cognitive impairments?: Choose an item. If yes, please explain:
Any Additional Comments:
Does the member require any special accommodations? (please check all options that apply)
Wheelchair☐ Ramp☐ Fully Handicap accessible☐ Grab bars in shower/commode☐ Ground floor needed
☐Vision Impaired☐ Hearing Impaired☐ Non-verbal☐ Other (please explain)☒
ACTIVITIES OF DAILY LIVING ASSESSMENT
Please answer the below items based on the below scale:
1 = Member is not able to complete/perform the task
2= Member needs constant oversight/prompts to complete/perform the task
3= Member needs some oversight/prompts to complete/perform the task
4 = Member is able to perform the task independently
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2
3
4
Able to keep place of living clean (vacuuming, dishes, dusting, cleaning, bathroom,
room, sweeping, moping).
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Able to wash clothes (sort clothing, Laundry facilities, and money).
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HOME MANAGEMENT
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Able to recognize potential dangers and avoid harm.
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Able to use appropriate emergency services (911, crisis, emergency department, case
manager, fire, doctor).
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Can identify and complete a plan in case of emergencies (fire, electrical).
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Can understand and is knowledgeable of basic first aid without supervision.
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Is aware of their personal safety (doors locked, use caution with strangers).
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Able to handle potentially violent and/or threatening situations in an appropriate
manner.
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Requires 24 hours monitoring due to overnight dangers (indicate specifics below)
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Able to select an appropriate wardrobe (weather, socially acceptable, events,
activities).
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Able to recognize and maintain good hygiene habits daily.
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Uses hygiene products daily for grooming techniques including hair, dental, bathing.
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Can contact the pharmacy for prescriptions and manage his/her prescriptions in their
home.
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Can take medications as prescribed
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Able to understand side effects and coordinate with their prescriber as needed.
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Able to recognize and maintain good hygiene habits daily.
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Are there any other skills needed in the home management area:
HEALTH AND SAFETY
Wandering ☐
Last date(s) of occurrence
Cognitive Impairments ☐
Last date(s) of occurrence
Cooking on Stove ☐
Last Date(s) of occurrence
Please explain any unsafe overnight behaviors:
PERSONAL HYGIENE MAINTENANCE and HEALTH AWARENSS
Are there any other skills needed in the personal hygiene and health awareness area:
MEAL PREPARATION
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Understands how nutrition impacts physical and mental health.
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Able to grocery shop on their own (budget, grocery list).
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Knows how to store and handle food to avoid sanitation concerns or eating unsafe
items.
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Able to cook meals
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Able to use a stove, microwave, oven, etc.
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Understands legal biding contracts (i.e. leases).
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Understands the impact of how paying bills on time can impact credit.
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Understands basic Arizona Landlord Tenant And Fair Housing laws.
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Can budget their money (daily, weekly or monthly budget, comparison shopping).
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Able to open a checking account.
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Can maintain their checking account and understand their Benefits ( SSI/SSDI, Food
stamps).
Needs a payee? No ☐ Yes☐
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Can organize and establish priorities in order of importance.
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Is able to manage their time so as to attend appointments and other responsibilities.
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Able to use and read a clock to plan activities.
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Can use a calendar to schedule appointments (doctor, groups, community activities,
work, and school).
Are there any other skills needed in the time management area:
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Are there any other skills needed in the meal preparation area: area:
MONEY MANAGEMENT and LEGAL
If payee is needed what is the status of request:
TIME MANAGEMENT
SOCIALIZATION SKILLS
Can recognize and avoid dangerous and abusive relationships and friendships.
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4
Able to understand social etiquette (social cues, triggers, boundaries, personal space).
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Able to learn how to inter-act and deal with others.
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Can use proper coping skills when dealing with stressful situations.
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Are there any other skills needed in the socialization skills area:
COMMUNITY SERVICES AND TRANSPORTATION
Knows how to find information on and attend social events and activities (12 step,
support groups, hobbies, and church groups).
Knows how and where to get identification cards and benefits (Birth certificate, ID,
bus card, AHCCCS card, food stamp card, Social security card).
Able to use public services (bus, bus book, maps, cabs, light rail, dial-a-ride, and the
orbit).
Currently involved in meaningful community activities No ☐ Yes ☐
Please describe activities member is participating in and frequency of attendance:
PLAN TO TRANSITION FROM SUPPORTIVE HOUSING PLACEMENT
Public Housing Authority Application: ☐
County or City applied for:
HUD 202 ☐
Own Apartment ☐
Date Public Housing Authority Application was Submitted: Click
here to enter a date.
Family Friends ☐
Other ☐
Please explain other:
SUMMARY:
CHOOSE THE APPRORIATE LEVEL OF CARE LISTED BELOW AND NOTE THIS LEVEL OF CARE IN
THE“ TYPE OF LIVING/TREATMENT ENVIRONMENT REQUESTED” BELOW
***{FLEX-CARE) OR {FLEX-CARE-CO) {UP TO 12 HOURS OF SERVICES AND SUPPORTS}
***{FLEX-CARE PLUS} OR FLEX-CARE PLUS-CO} {12 OR MORE HOURS OF SERVICES AND SUPPORTS}
***{FLEX-CARE-PLUS-EXT} OR (FLEX-CARE-PLUS-EXT-CO) {UP TO 23.9 HOURS OF SERVICES AND SUPPORTS}
Type of Living/Treatment Environment requested: Choose an item.
What are the specific needs and behaviors placement treatment setting placement?:
What are the expected outcomes expected from participating in a supportive housing treatment setting
placement?:
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Signature Page
I hereby attest that the information provided on this assessment is the most current and that the member is in
agreement with a referral for supportive housing:
Person Completing the Assessment:
Clinical Coordinator/Liaison:
date.
Clinical Director:
Psychiatrist:
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Signature:
Signature
Title:
Signature:
___________
Date: Click here to enter a date.
___________________
__
__________________
Date: Click here to enter a
Date:Click here to enter a date.
Date: Click here to enter a date.