LS / DD Family Support Program Renewal Application Packet In-home support to families who have children with severe disabilities Manitowoc County Human Services Department Developmental Disabilities Services 926 S. 8th Street P.O. Box 1177 Manitowoc, WI 54221-1177 Mary Ann Johnson (920) 683-4241 Lisa Stephan (920) 683-2792 The Family Support Program is a state-wide program aimed at relieving some of the stress families who have children with severe disabilities face, and enhancing their ability to care for their child at home. The program offers information, and help, in accessing resources and funding to purchase needed goods, or services, that are not otherwise available. This application will assist program staff in learning more about the unique needs or your family, and in potentially working with your family to develop a plan for meeting the needs of your family. Date Completed: 4/09 Completed By: Child’s Last Name Date of Birth Child’s First Name SSI# Parent(s) Name(s) Home Telephone # Household Members: Name Middle Initial Sex Medical Assistance ID # Address Work Telephone # Date of Birth Relationship please attach sheet if more space is needed Diagnostic Information Diagnosis Name of Physician Making Diagnosis Date of Diagnosis Please briefly describe your child’s current condition. Please note any changes to his/her condition within the last year. Also please list strengths of your child. Physicians and Specialists Name- Primary Health Care Provider Type Address (Street, City, State, Zip Code) Telephone Number Name – Psychiatrist Type Address (Street, City, State, Zip Code) Telephone Number Name Type Address (Street, City, State, Zip Code) Telephone Number Name Type Address (Street, City, State, Zip Code) Telephone Number please attach sheet if more space is needed Hospitalization or out of home placement history List inpatient hospitalization (including psychiatric), institutional placement or foster care/group home placement for the past year. Include facility name, dates, address and reason. If you need additional room please attach a separate sheet. 1. 2. 3. Please attach sheet if more room is required Social Service Providers / Resources Birth to 3 Program Community Options Program (COP) Respite Care Substance Abuse Services Child Protective Services Other: Specify I understand that personally identifiable information on this form is used to help determine eligibility for Children’s Long Term Support Services. I certify, under the penalty of perjury, that the information on this application and given in connection with it is a true and complete statement of facts according to my best knowledge and belief. I also understand that I may be asked to provide proof of any information given on this application form and that giving false information may subject me to prosecution for fraud. _______________________________ SIGNATURE –Child (If age 14 years or older) Check here if child is unable to sign _____________________________________ ______________________ SIGNATURE – Parent or Guardian Relationship to Child ___________________ Date Signed ___________________ Date Signed The final page of this application is where you are requested to identify what the needs of your family are to keep your child in your home. Needs are placed into 4 categories including crisis, at-risk, maintenance, and enhancement. Please review the following definitions of the 4 categories and place the needs of your family into the category you best feel it fits. A. Crisis Category: Where funds would be provided to prevent an imminent crisis situation. B. At-Risk Category: Funds provided to families with at risk factors that increase the likelihood of a crisis situation. At risk is also defined as an unmet need that would result in greater impairment to the child. C. Maintenance: Funds needed to continue the quality of care and service level recognized as necessary for maintaining the child in the home. D. Enhancement Category: Funding provided to enhance the quality of care and service level for the child, but not necessary for continued success in the home environment.