Linn County Community Services Building MHDD Intake Office

Linn County Community Services Building MHDD Intake Office 1240 ~ 26 th Avenue CT SW, Cedar Rapids, IA 52404 Phone: (319) 892-5671 FAX: (319) 892-5679 0ffice hours: 8am-4:30pm, Monday-Friday (except holidays) General E-mail address: mhddintake@linncounty.org 1. FILL OUT ALL PAGES IN THIS PACKET TO THE BEST OF YOUR ABILITY, OR ASK SOMEONE TO HELP YOU. (If you don t understand something, call 319-892-5671 for further explanation.) 2. PLEASE CALL (319) 892-5671 to make an appointment. If you are unable to come in for an appointment, provide copies of all supporting documents listed below and e-mail, mail or fax (319-892-5679) them to our office. 3. BRING THE FOLLOWING ITEMS THAT RELATE TO YOU OR OTHERS IN YOUR HOUSEHOLD: A. Identification: Picture ID, Social Security Card, or Birth Certificate B. Proof of last 30 days of entire household income: Work Check Stubs Unemployed: obtain printout from Iowa Works (lower level of Lindale Mall) with last 4 quarters of income Unemployment received: obtain a printout from Iowa Work Force Development office showing payments Income Taxes: if married or filing joint income taxes with someone in the household or claimed by another person on their taxes, you must also provide proof of their income. Social Security (for household): if benefits are pending, bring most recent letter from SS office/attorney Child Support received: must have proof, listing payments received for each child Alimony received: amount receiving Pension(s)/VA Benefits FIP: (Family Investment Planning) Self-Employed: current tax returns or documentation of previous 30 days of self-employment income Any other sources of Income Not Listed Above C. Provide proof of resources below: Checking Account(s), Savings Account(s) Account balances from payee, Hinzman or Nelson Centers, residential care facilities Residential Trust Account Certificates of Deposit Trust Funds/Inheritance Life Insurance (Cash Value) Retirement (Cash Value) Stocks/Bonds/Mutual Funds Assessed Value of all Rental Property or Business Any other proof of Resources Not Listed Above D. Health Insurance Card (Medicare, Medicaid, Private insurance) Revised 9/11, Page 1

12 th St SW Directions To Our New Location: 1240 ~ 26 th Avenue Ct SW, Cedar Rapids, IA 52404 N Revised 9/11, Page 2

LINN COUNTY MHDD LEGAL SETTLEMENT HISTORY Date: APPLICANT S NAME: SSN: DOB: IN THE PAST 10 YEARS, HAS THE APPLICANT LIVED CONTINUOUSLY IN LINN COUNTY? YES skip this page NO Continue this page Please complete the following information with as much detail as possible. This does not affect your eligibility for funding; it only determines which county is responsible. Begin with your current address. Continue completing each address section until it is clear IN WHICH COUNTY YOU HAVE BEEN FOR 12 MONTHS without receiving any of the services listed. Current Address: City, County: Dates: Services while at this address: Provider(s) Dates of Service Mental Health/Substance Abuse outpatient treatment or short-term residential (psych doctor/counselor/group therapy Mental Health or Substance Abuse hospitalization, including local hospitals or Mental Health Institutes (MHI) Case management, in-home or community support services Vocational Rehabilitation, Goodwill, Options, or stays at Emergency shelters Prison/Jail/Hinzman/Nelson Center Current Previous Address: City, County: Dates: Services while at this address: Provider(s) Dates of Service Mental Health/Substance Abuse outpatient treatment or short-term residential (psych doctor/counselor/group therapy Mental Health or Substance Abuse hospitalization, including local hospitals or Mental Health Institutes (MHI) Case management, in-home or community support services Vocational Rehabilitation, Goodwill, Options, or stays at Emergency shelters Prison/Jail/Hinzman/Nelson Center If more room is needed, use back side and/or additional paper. If faxing, ensure back side is included!!! NOTES: OFFICE USE ONLY LEGAL SETTLEMENT DETERMINED: DATE: Signed: Revised 9/11, Page 3

Legal settlement continued if additional room is needed: Previous Address: City, County: Dates: Services while at this address: Provider(s) Dates of Service Mental Health/Substance Abuse outpatient treatment or short-term residential (psych doctor/counselor/group therapy Mental Health or Substance Abuse hospitalization, including local hospitals or Mental Health Institutes (MHI) Case management, in-home or community support services Vocational Rehabilitation, Goodwill, Options, or stays at Emergency shelters Prison/Jail/Hinzman/Nelson Center Previous Address: City, County: Dates: Services while at this address: Provider(s) Dates of Service Mental Health/Substance Abuse outpatient treatment or short-term residential (psych doctor/counselor/group therapy Mental Health or Substance Abuse hospitalization, including local hospitals or Mental Health Institutes (MHI) Case management, in-home or community support services Vocational Rehabilitation, Goodwill, Options, or stays at Emergency shelters Prison/Jail/Hinzman/Nelson Center Previous Address: City, County: Dates: Services while at this address: Provider(s) Dates of Service Mental Health/Substance Abuse outpatient treatment or short-term residential (psych doctor/counselor/group therapy Mental Health or Substance Abuse hospitalization, including local hospitals or Mental Health Institutes (MHI) Case management, in-home or community support services Vocational Rehabilitation, Goodwill, Options, or stays at Emergency shelters Prison/Jail/Hinzman/Nelson Center Employment History: (list starting with most recent to all previous. Use another sheet if more space is needed) Employer City, State Job Title/Duties To/From 1. 2. 3. Revised 9/11, Page 4

LINN COUNTY MHDD INTAKE SERVICES ENROLLMENT FORM Date: PERSONAL INFORMATION OF APPLICANT Applicant s Name: SSN: Aliases/AKA/Maiden or other names known by: Address: Phone(s): Number and Street City/State/Zip Code Birth date: Sex: Male Female Veteran: No Yes If yes, Veteran Discharge Status: Honorable Dishonorable Other Have you applied for VA benefits? Yes No Ethnic Background (Check One): White African American Native American Asian Hispanic Other Marital Status (Check One): Never Married Married/Common Law Divorced Separated Widowed Check actual number of years of education completed: 1 st -8 th 9 th 10 th 11 th 12 th /GED 13 th 14 th 15 th 16 th 17 th + Email address (optional): HOUSEHOLD INFORMATION Residential Arrangement: Private Residence Homeless Foster Care Correctional Facility Other Supported Community Living (CSA/SCL) State Resource Center Mental Health Institute (MHI) RCF RCFMR RCFPMI ICF ICFMR ICFPMI Living Arrangement: Lives Alone With Spouse Kids Relatives Unrelated People Other household members (or any additional dependents claimed on taxes, even if not in household) (List additional dependents on the back of this page) Relationship Date of Birth Family or Emergency Contact: Name: Relationship: Phone: ( ) Revised 9/11, Page 5

LEGAL STATUS Do you have a legal guardian, conservator or protective payee? Not Applicable Legal Guardian Name Address Phone Protective Payee Name Address Phone Conservator Name Address Phone HEALTH INSURANCE INFORMATION Primary Carrier (pays first) Secondary Carrier (pays second) No Insurance T19-Medically Needy No Insurance T19Medically Needy Private Insurance Hawk-I Private Insurance Hawk-I Medicaid (T19) Medicaid (T19) Medicare Medicare Part A Part B Part D Part A Part B Part D Company name: Company name: Address: Address: Policy Number Policy Number Effective Date: Effective Date: APPLICANT S PRIMARY DIAGNOSIS (Provider Use Only) Mental Illness: Type: DSM-IV: ICD 9 CODE: Mental Retardation: Type: DSM-IV: ICD 9 CODE: Developmental Disability: DSM-IV: ICD 9 CODE: Other: Describe DSM-IV: ICD 9 CODE: EMPLOYMENT STATUS UNEMPLOYED AND UNAVAILABLE FOR WORK Applied for SS/SSI/SSDI? No Yes ~~> UNEMPLOYED AND AVAILABLE FOR WORK If yes, Status: Pending-Date: Denied -Date: Appeal Filed Date: Attorney s Name: Last Date Worked: Applied for unemployment? no yes If yes, Status: Employer: EMPLOYED - full time part time Hourly wage: $ Hours per week: Homemaker Student Seasonal Supported Employment Shelter Work Activity Center Voc Rehab Military Retired Other If you have no income, how do you pay your bills? (Please do not leave this blank if no income is reported!) Revised 9/11, Page 6

GROSS MONTHLY INCOME (MUST PROVIDE PROOF) Payment Frequency W=weekly, BM=twice a month BW=every 2 weeks; M-once a month Earnings (GROSS) W BW M BM 2 nd Job/Income W BW M BM Unemployment W BW M BM Pensions/Retirement W BW M BM Alimony/Child Support W BW M BM Dividends/Interest W BW M BM Social Security W BW M BM Social Security Disability W BW M BM SSI W BW M BM Veteran s Benefits W BW M BM FIP (ADC) W BW M BM Food Stamps Other not listed above W BW M BM M Applicant s Amount Others in Household ( G r o s s P e r M o n t h ) Omit Household Income, as applicant is a minor and applying for Case Management Services ONLY Relationship To Applicant HOUSEHOLD RESOURCES (must provide proof of all accounts and balances) Cash on Hand $ Checking Account(s) Balance Bank: Bank: Savings Account(s) Balance Bank: Bank: Payee Account Balance Payee: Residential Trust Account Location: Certificates of Deposit Bank: Trust Funds/Inheritance Trustee: Life Insurance (Cash Value) Co.: Stocks/Bonds/Mutual Funds Co.: All vehicle(s) in your name Value: Year/Make/Model: All Real Estate Value: Value: Year/Make/Model: Does anyone need to be notified of MHDD approvals or denials (Probation officer, social worker, etc.)? Name: Phone: Fax: Email: Person Completing the Form, if not applicant: Name: Phone: Fax: Email: If case manager, what is ISP date? Relationship: Relationship: As a signatory of this document, I certify that the above information is true and complete to the best of my knowledge, and I authorize Linn County CPC or Intake staff to check sources for verification of the information provided. I understand that the information gathered in this document is for the use of Linn County in establishing my ability to pay for services requested, in assuring the appropriateness of services requested, and in confirming legal settlement. I understand that I must report within 30 days any changes in my situation, which could affect my eligibility. I understand that information in this document will remain confidential. Applicant Signature (or Legal Guardian) Date Revised 9/11, Page 7

LINN COUNTY MHDD SERVICE AUTHORIZATION REQUEST Date: Applicant s Name: Client SS#: - - Mailing Address: Date of Birth: - - Has the Applicant completed an enrollment for Linn County MHDD Services in the past 12 months? Yes No SERVICES BEING REQUESTED: C A T E G O R Y I S E R V I C E S C A T E G O R Y II S E R V I C E S 1. Commitment (COM) 8. Adult Day Treatment (ADT) 23. RCFPMI (RCFP) 2. Evaluation (EVAL) 9. Adult Daycare (ADC) 24. Rent Subsidy Residential (RS) 3. Individual Therapy/Treatment (TT) 10. Client Participation Waiver (CP) 25. Respite (RP) 4. Medication/Medical Residential (MEDR) 11. Clubhouse (CH) 26. Supported Comm Living-Residential (SCL) 5. Psychotropic Medication (MEDI) 12. Community Support Program (CSP) 27. Supported Comm Living-Independent (SCLI) 6. Psychotropic Medication (MEDH/MEDHR) 13. Day Program Services (Day P) 28. T-19 Case Mgmt. (19CM) 7. Rent Subsidy Independent Living* (RSI) 14. Group Treatment & Therapy (GP) 29. VOC Comp-Supported Employment (V-SE) *Service # 7 will require additional paperwork from a support worker. 15. Guardian (GRD) 30. VOC Enclave (V-EN) 16. Mental Health Institute (MHI) 31. VOC Job Placement (V-JP) 17. MR Counseling (CL) 32. VOC-Leased Employment (V-LE) 18. Non T-19 Case Management (NCM) 33. VOC Shelter (V-SH) 19. PACT (PACT) 34. VOC WAC (V-W) 20. Partial Hospitalization (PH) 35. VOC WAC Intensive (V-WI) 21. RCF (RCF) 36. Voluntary Hospitalization (VOL) 22. RCFMR (RCFM) 37. Other Agency Name Service Requested # # Monthly Units Unit Cost Expected Start Date Expected End Date (1) (2) (3) (4) (5) (6) (If requesting more than 6 services, please complete a second Service Authorization Request form to avoid errors.) What services or assistance are you looking for? Contact person if questions arise regarding this request: Name: Address: Phone: Fax: Email address: Person completing the form (if not applicant): Name: Agency: Phone: Fax: Email address: Indicate relationship to applicant: Guardian Hospital Protective Payee Case Mgr Other As a signatory of this document, I certify that the above information is true and complete to the best of my knowledge, and I authorize Linn County CPC or Intake staff to check sources for verification of the information provided. I understand that the information gathered in this document is for the use of Linn County in establishing my ability to pay for services requested, in assuring the appropriateness of services requested, and in confirming legal settlement. I understand that I must report within 30 days any changes in my situation, which could affect my eligibility. I understand that information in this document will remain confidential. Applicant Signature (or Legal Guardian) Date Revised 9/11, Page 8

LINN COUNTY MHDD INTAKE SERVICES 1240-26 th Avenue Ct. SW, Cedar Rapids, IA 52404 Phone: (319) 892-5671 FAX: (319) 892-5679 A U T H O R I Z A T I O N F O R R E L E A S E O F I N F O R M A T I O N NAME: SS# ADDRESS: DATE OF BIRTH: Parent/Guardian (If applicable) Address: I authorize Linn County and the following individuals or agencies to have written and oral communication about my needs and services that I receive or have received, so that the County may determine my eligibility for assistance. N a m e / A g e n c y : ABBE CENTER, CEDAR CENTER, CMHC, MERCY & ST. LUKES HOSPITALS, SOCIAL SECURITY, JAILS, DHS, GENERAL ASSISTANCE, FOUNDATION 2, NOVUS/ASAC/HEART OF IOWA, DEPT OF CORRECTIONS & Relevant offices from other counties I may have lived (CPC, auditor). Other: Date of Service/Treatment: Past 10 years thru current Past 10 years thru current Past 10 years thru current Past 10 years thru current Information Concerning: Psychiatric/Psychological Financial Institutions and Employers Pharmaceutical Client Services Dept. of Human Services Medical/Physical SSI/SSDI Motor Vehicle Educational Insurance Residential Dental Child Support Records Vocational Other: I further authorize the release of the following information, which requires specific consent under federal or state law: (This information may be released to Linn County Intake Office but not re-released to other entities, because such information can only be released by the original source.) T Y P E O F I N F O R M A T I O N N A T U R E A N D S O U R C E O F I N F O R M A T I O N INITIALS REQUIRED Mental Health Evaluation/Treatment Eligibility for county funded and coordination of services Substance Abuse Eligibility for county funded and coordination of services HIV/AIDS-related Eligibility for county funded and coordination of services N/A Signed Date Parent/Guardian (if applicable) Date Do you want a copy of this release? YES NO I understand this information shall be kept confidential and will be used for the purposes of planning and delivering my services. I understand that I have the right to see this information at any time. This consent is valid for information already in existence and any information which may be generated during future services involvement. I understand that I can revoke my consent at any time by providing written notification. This consent shall expire upon termination of Intake Services or within one year, whichever is first. I have read this form, or it has been read and explained to me, and I understand its content. Revised 9/11, Page 9

LINN COUNTY COMMUNITY SERVICES MHDD Intake Services 1240-26 th Avenue Ct. SW Phone: (319) 892-5671 Cedar Rapids IA 52404 Fax: (319) 892-5679 TO WHOM IT MAY CONCERN: I declare that all information provided by me is true and accurate, to the best of my knowledge. I agree to inform the agency of any changes in my household income or insurance that may occur within my eligibility period. I further attest that all personal information contained in my file may be released to the drug manufacturer if it is necessary to obtain my medication. I understand that if I request pharmaceutical assistance from Linn County MHDD, my information including demographics, diagnosis, and psychotropic medications would be entered into a secure database which Linn County MHDD and Abbe Community Mental Health Center have access to. I authorize Linn County MHDD Intake staff or Abbe Mental Health Center staff to sign necessary pharmaceutical applications for me or complete other tasks that are necessary to obtain my medication. I understand that this release is for the purpose of obtaining my medications, enrolling me in the prescription assistance programs or for auditing purposes only. I understand that I can revoke my consent at any time by providing written notification. This consent shall expire upon termination of Intake Services or within one year, whichever is first. I have read this form, or it has been read and explained to me, and I understand its content. PRINTED NAME: SIGNATURE: SOCIAL SECURITY: DATE OF BIRTH TODAY S DATE: / / Advocate Name: Advocate Number: