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RESPITE ASSESSMENT
Section I: (Request < 20 Hours/Month)
Beneficiary Name: (First, MI, Last)
Client Case#
Date Completed
Name of Parent / Guardian / etc.: (First, MI, Last)
Relationship to Beneficiary
Clinician Completing Form (First, MI, Last)
Clinician’s Program
Date Request Submitted
IPOS Date
ESTABLISH MAXIMUM AMOUNT OF RESPITE CARE TO BE AUTHORIZED ON A MONTHLY BASIS
Initial Questions:
1. Does client / family qualify for services through GCCMH?
YES
NO
2. Does client meet guidelines for receiving Medicaid reimbursable services?
(If “No”, STOP HERE.)
YES
NO
3. Does client/recipient have a documented diagnosis of:
a. Developmental Disability (DD)?
YES – List:
b. Severe & Persistent Mental Illness (SPMI)?
YES – List:
c. If child, Serious Emotional Disturbance (SED)?
YES – List:
d. None of the Above
4. Why are you requesting Respite Care? How will it be used? (Please be specific – this is critical.)
Describe:
Verified that Respite Care is not to supplant or replace childcare responsibilities, nor is it to be repetitive daily care that is more
consistent with Community Living Services.
YES, I agree with verification statement.
NO, I do not agree. If “No”, refer as appropriate for other services.
5. Does the beneficiary reside in a non-licensed home setting (independent living)?
YES
If
NO, then describe:
6. Does the client have an unpaid primary care giver responsible for day-to-day support in order to maintain independent living?
YES
If
NO, then describe:
Number of caregivers residing in the beneficiary’s home, or the number of primary caregivers providing direct support and care to the
beneficiary if he/she resides in own residence:
7. Have other sources of respite been pursued for respite supports? (e.g., family, friends, church, others -- has the client looked for
other ways to provide the needed break in caregiving?)
YES -- Describe:
NO -- Pursue other avenues of natural supports first.
8. Complete and insert written Respite goal with amount, scope, and duration, as will be included in the IPOS.
Goal:
9. List the objectives of this Respite request and document the measurable outcomes.
Objectives & Measurable Outcomes:
10. Is dependent or other family member receiving any other support services?
YES. Describe them along with hours, money, etc:
No. Enter “0” zero:
Client Name:
DOB:
Section 4
Staff Name:
Last revised: November 15, 2007
Case Number:
Page 1 of 7
Medicaid Number:
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RESPITE ASSESSMENT
11. How much Respite care are you requesting? (monthly need, single occasion, vacation, etc.)
Monthly Needs
:
(Hours)
Special Occasion
:
(Hours)
Describe Purpose:
SELECT ONE PREFERRED PROVIDER: (Mark the client’s/caregiver’s selection of a Preferred Provider (organization) for
Respite Support Services below. Individual Respite workers will become employed under the selected company serving this client.
This organization will help in scheduling the time, place, and workers that serve the client’s needs)
Expert Care
Helping Hands
Independent Home Care
MCSI
SELECT ONE PROVIDER TYPE: (Please include the program code.)
Aide
Code:
LPN
Code:
RN
Code:
Choose appropriate Funding Stream(s) from your specialty area only:
Case Management
5571 Respite Services
Waiver (DD)
Child & Family Services
Dir. Of Children’s Services
or Specified Designee
Respite Only - Respite Liaison
5571 Respite Services (DD)
5571 Respite Services
5737 CMH Children’s
5171 Grant: Tobacco Tax (SED<18)
5221 Grant: SFSC Respite Post Adopt
5177 Grant: Wrap-around
5171 Grant: Tobacco Tax (SED<18)
Additional statements for consideration, including special needs, medical conditions of the client and family, etc.
Please list:
This consumer has been deemed eligible for GCCMH services according to the contract attachment
descriptions for SPMI, SED, or DD.
Complete Section I – Respite Assessment for ALL beneficiaries. If requesting < 20 hours respite per month, sign the hard
copy of this form for your file, and attach a copy of this form to an email and send it to the Respite Coordinator in CMH
Utilization Management for Authorization purposes
_________________________________________________
_______________
________________
Clinician Signature /Credentials
Date
Time Submitted
_________________________________________________
_______________
________________
Liaison Signature
Date
Time Submitted
Client Name:
DOB:
Section 4
Staff Name:
Last revised: November 15, 2007
Case Number:
Page 2 of 7
Medicaid Number:
Address Here
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RESPITE ASSESSMENT
Section II: (Request > 20 Hours/Month)
Beneficiary Name: (First, MI, Last)
Client Case#:
Date:
INSTRUCTIONS:
Read the left-hand column for all that apply. Place your mark in the checkbox after the Yes column beside the appropriate item.
Provide additional descriptive details regarding the item in the far right column. If none of the statements in a left hand box applies,
please write N/A (Not Applicable) in the far right column.
Family Situation/Resource Consideration
Clinical Notes - Expand
Describe:
Availability of Caregivers Living in the Home

2 or more caregivers; both work or are in school F/T or P/T
Yes:

2 or more caregivers; 1 works or is in school F/T or P/T
Yes:

2 or more caregivers; neither works nor is in school at least P/T -
List Caregiver conditions and impact upon care giving:
Yes:

1 caregiver; works or is in school F/T or P/T
Yes:

1 caregiver; does not work and is not a student
Yes:

Does Primary Caregiver have a health, psychological or emotional
condition that:
Prevents the provision of care
Yes:
Interferes with the provision of care
Describe:
Yes:
Additional Supports and Services
Describe details: (Also transfer info from Section I, Q6)

Additional supports in the form of CLS/staff
Yes:
School


Describe:
Number of Hours in school/out of home. Program time +
transportation time generates daily or weekly hours
Yes:
Beneficiary is age 6-16 and there is not medical justification for a home
bound school program; or 6-24 if DD
Yes:
Additional Considerations

Describe:
Frequency of nighttime interventions (Document Condition)
Yes:
1-2 Night Time Interventions per night
3-4 Night Time Interventions per night
More than 4 Night Time Interventions per night
Additional supporting details and comments:
Client Name:
DOB:
Section 4
Staff Name:
Last revised: November 15, 2007
Case Number:
Page 3 of 7
Medicaid Number:
Address Here
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RESPITE ASSESSMENT
SECTION INSTRUCTIONS:
Use the boxes below to guide the selection of the category that best describes the client on an average or typical day. Describe the
usual functional level of the client. **If the client’s ability is lower at times (due to illness, behaviors, etc.), rate the average functioning
level that would most commonly describe the client.
Each heading has a subset of three bolded verbal descriptors. Under each of the bolded descriptors is a list of individual statements
that would be used to define characteristics consistent with the bolded line above. Read the individual selections under the bolded line
and select all those that are characteristic of the client on a daily or weekly basis. If the behavior is not prominent or has not occurred in
the last 30 days, do not include the description. Mark all that apply.
BEHAVIORAL/EMOTIONAL
Behaviorally/emotionally independent; calm demeanor.
Plays well alone (appropriate use of tools, toys, etc.).
Plays and interacts easily with others with little anxiety. Not inappropriately excitable.
Sexually appropriate behaviors.
Other mild behavioral problems. List:
Behaviorally/emotionally dependent upon others.
Occasional verbal outbursts, then resumes activities.
Functions well after project is set up for client. Occasional prompting.
May wander if not reminded to stay in location while on task.
Occasional sexually inappropriate verbalizing or touching.
Basic behavior plan currently in place
Other moderate behavioral problems. List:
Behaviorally/emotionally dependent; frequent verbal and or physical outbursts.
Prone to unprovoked fits of anger and rage.
Physically abusive to self. Hitting, biting, kicking.
Physically abusive to others. Hitting, biting, kicking.
Engages in physical sexually inappropriate behaviors or public self-stimulation.
Engages in verbally or sexually inappropriate behaviors.
Extensive behavior plan currently in place.
Other severe behavioral problems. List:
MOBILITY
.
Physically independent with good basic judgment about safe mobility.
If in a wheelchair or walker, maneuvers it and transfers independently.
If in a wheelchair, is aware of need to maintain skin integrity and initiates interventions to prevent skin
breakdown.
Uses landmarks to get around the local neighborhood.
Crosses the street safely (per staff report).
Physically independent with group supervision required for safe judgment about mobility.
Knows how to get to the mailbox independently but needs assistance to get to other landmarks.
Can sit on the porch or be in the yard unsupervised for a brief period of time but CANNOT get around the
neighborhood/outside of the yard.
Stays in the house or yard but needs group supervision to prevent wandering when in the community.
If uses a wheelchair or walker, needs stand by assistance during transfer or on uneven terrain.
Needs reminders to use wheelchair brakes correctly.
Needs group supervision to cross street safely.
Physical assistance or 1:1 supervision required for safe mobility.
May follow anyone anywhere and needs staff supervision to prevent wandering out of the house.
Needs 1:1 assistance to enter/exit transportation service.
Relieves pressure off buttocks when sitting in wheelchair when assisted (verbally or physically).
Walks or transfers with one-person assistance.
Needs to be pushed in wheelchair within house.
Client Name:
DOB:
Section 4
Staff Name:
Last revised: November 15, 2007
Case Number:
Page 4 of 7
Medicaid Number:
Address Here
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RESPITE ASSESSMENT
Needs assistance of 2 people to walk or mechanical lift for transfer.
Cannot reposition self/needs to be repositioned every 2 hours by staff .
Needs specialized treatment to maintain mobility (muscle tone management and/or ROM).
Needs 1:1 on outings (crossing streets, being in buildings, etc). Document in “OUTING.”
Other:
BARRIER-FREE STATUS
NO - Does not need barrier-free home.
May use wheelchair or walker for distances only (able to move around inside home and navigate 2 or more
steps independently).
YES - Needs barrier-free home.
Uses wheelchair or walker majority of the time.
Needs supervision or assistance for safety on or around steps.
SELF CARE
EATING:
Can serve self, cut food, open all containers, and eat without staff assistance.
If physically disabled, uses adaptive equipment independently.
Other:
Can eat after set-up by staff; however, needs group supervision.
Needs assistance only to open unusually packaged foods and cut tough foods.
Requires assistance for cutting, opening, and serving food.
Group supervision is required to take appropriate sized bites or to slow down.
Needs group supervision to provide prompts to continue eating (becomes distracted).
Needs group supervision reminders to wipe face as food may be spilled, dropped, or smeared around mouth
without awareness of mess.
Other:
Needs 1:1 staff assistance to eat, set up adaptive equipment, modify texture of food, or eat
at appropriate rate.
Needs adaptive equipment, however uses it independently after staff sets it up.
Food texture modification – small bite size
Food texture modification –
only meat ground;
meat & more ground;
pureed
Food texture modification - thickened liquids.
May need frequent monitoring of blood sugar levels to determine what food is provided.
Needs 1:1 supervision to slow down or speed up &/or physical assistance to hold/use spoon or cup.
May need special positioning prior to meal to prevent reflux or aspiration.
Tube fed.
Fed by staff.
Other:
TOILETING:
Can locate and use a clearly marked bathroom in a new/unfamiliar setting without direction.
If uses a wheelchair or walker, transfers to toilet and navigates facility independently.
If needs catheterization, handles all daily care independently.
If needs a catheter, may need specialized/medical assistance on a periodic basis (i.e., change catheter
monthly).
Other:
Recognizes need to void, finds toilet in familiar setting, and cares for self at the toilet with
minimal reminders.
May need to have garment errors pointed out.
May need help with set up (having toilet paper, etc).
Client Name:
DOB:
Section 4
Staff Name:
Last revised: November 15, 2007
Case Number:
Page 5 of 7
Medicaid Number:
Address Here
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RESPITE ASSESSMENT
May leave door open and/or forget to flush.
If uses a catheter, needs reminders for proper use.
Occasional accidents but cares for cleanup independently.
May need verbal assistance to use toilet paper.
May need verbal assistance for clothing management (pull down/up or fasten pants).
Other:
Requires 1:1 verbal or physical assistance to use the bathroom.
May be on a toileting schedule.
May need physical assistance to use toilet paper.
May need physical assistance for clothing management (pull down/up or fasten pants).
May need physical assistance to transfer to and from toilet.
May need mechanical lift to transfer to and from toilet.
May wear adult briefs at night, for outings, or during transport, and needs assistance to clean self.
Wears adult briefs all day and night and needs total assistance to clean self.
May need monitoring of bowel activity and resulting diet or medication changes.
May need direct/physical intervention for bowel mobility (ex: suppositories, enema or digital removal).
If uses a catheter, needs verbal prompts and standby assistance for application.
If uses a catheter, may need daily care by staff to catheter site.
May be Dependent Care Plan for intermittent catheterization or Foley care.
Other:
BATHING:
Bathes without assistance and checks own quality.
If physically handicapped, is/can be independent with adaptive equipment.
Other:
Bathes independently; however, needs reminders for thoroughness.
May need to be checked for thoroughness.
May need verbal prompts to pick up afterward.
Needs initial set up including adjusting water temperature but then is independent.
Other:
Requires 1:1 verbal prompts and/or physical assistance by staff.
.
Needs verbal and/or standby assistance to use a tub seat or grab bars at beginning and end of bath only.
May require assistance throughout the task for the following reason(s) (check ALL that apply):
To maintain safe water temperature
To wash body parts/hair thoroughly
To maintain safe positioning
Needs extra time due to use of specialized adaptive equipment to enter/exit tub: (check ALL that apply)
2-person lift.
Mechanical lift.
Other:
DRESSING:
Selects own clothes and dresses without error.
If adaptive equipment is needed/used, it is used independently.
Other:
Follows a routine in getting dressed without physical assistance.
Needs verbal reminders to correct errors in button alignment, zipper completion, etc.
Needs verbal reminders to coordinate clothes.
Needs assistance to start or finish.
Needs brief (a few seconds) assistance with difficult items (ex: bra, small zippers, socks, shoes, etc.) only.
Needs verbal reminders to choose clothes that are weather appropriate or change clothes that are soiled.
Other:
Needs physical assistance and/or set up by staff.
Uses adaptive equipment after set up by staff.
Requires assistance throughout dressing for the following reason(s):
Needs physical support for sitting/standing balance while dressing.
Needs constant verbal prompts throughout dressing task.
Totally dependent.
Client Name:
DOB:
Section 4
Staff Name:
Last revised: November 15, 2007
Case Number:
Page 6 of 7
Medicaid Number:
Address Here
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RESPITE ASSESSMENT
Other:
TOOTHBRUSHING:
Initiates and completes toothbrushing without assistance
If adaptive equipment is needed/used, it is used independently.
Other:
Initiates and completes toothbrushing with reminders for thoroughness.
May miss spots that are seen when pointed out.
Initiates task at correct time, however, may need to be reminded now and then.
May not be aware of the time of day that these tasks need to be done.
Other:
Completes toothbrushing with set-up and verbal prompts.
May need adaptive equipment set up for them.
May need 1:1 supervision to get started but then completes it on their own.
May need frequent verbal prompts throughout the task.
Needs total physical assistance.
Other:
HAIR CARE:
Initiates and completes hair care without assistance.
If adaptive equipment is needed/used, it is used independently.
Other:
Initiates and completes hair care with reminders for thoroughness.
May neglect the back of the head or body or may miss spots that are seen when pointed out.
Initiates task at correct time. However, may need to be reminded now and then.
May not be aware of the time of day that this task needs to be done.
Other:
Physical assistance or 1:1 supervision is required.
May need adaptive equipment set up for them.
May need 1:1 supervision to get started but then completes it on their own.
May need frequent verbal prompts throughout the task.
Has special hair treatment needs (i.e., medications, hair oils, etc.).
Needs total physical assistance.
Other:
Clinician Signature/Credentials
Date
Time Submitted
Liaison Signature
Date
Time Submitted
Final Instructions: You have now completed Section I and Section II of the Respite Assessment form. Attach a copy of
this form to an email and send it to the Respite Coordinator in CMH Utilization Management for Authorization purposes.
Client Name:
DOB:
Section 4
Staff Name:
Last revised: November 15, 2007
Case Number:
Page 7 of 7
Medicaid Number: