STEP #1
(If we have already spoken and have set up a phone appointment, please go to step #2)
Set a phone appointment with me. your Intake Rep for the Agency for Persons with Disabilities
Hello,
My name is Destry LeBrun and I'm the Intake Specialist with the Agency for Persons with Disabilities who's been assigned to get your Medicaid paperwork sorted.
I need to have a phone conversation with you soon so I can gather the information needed to submit the paperwork and documentation to the main company office.
The phone conversation should take about 60 minutes if you do not send me the requested information (attached) beforehand, or 30 minutes if you do.
You don't need to include identifying information in your email. I already have all the personal ID information I need or can get during our phone conversation. Just describe the applicant as if the people who will determine their eligibility will never meet them but feel as they know them. Please exclude anything you do not want included (considering the lack of privacy when using e-mail).
If this does not make sense or you would like more clarification, please text or call me at 850-375-4790.
Are any of the following times and dates good for you to spend some time on the phone with me?
Wed. the 26th - between 10am-12pm
Thur. the 27th - between 9am-11am
Fri. the 28th - between 10am-12pm
Please respond asap with the date and time you wish to reserve. Spots will fill up fast.
I will receive your communication much faster if you text me at 850-375-4790. If you prefer, you can e-mail me at destry.lebrun@gmail.com.Please see the attached Word document for the questions that are on the final report. I have also included a Word document with links that I think you will find helpful. You may return the answered questions in any way you prefer. However, if it is more convenient for you, please send me an email with the typed-out answers, without headlines. I will take care of the rest.
Sincerely,
Destry W. LeBrun
Intake Specialist
Agency for Persons with Disabilities
STEP #2
Send a text or e-mail to destry.lebrun@gmail.com or 850-375-4790 with the answers to the following questions:
People to contact if we need to speak with you but you are not available
Please provide any or all of the following information for each contact person:
Name, address, phone number and e-mail please
Guardian
Mother
Father
Other Relatives
Friends
Is there anyone else?
Programs/ Agencies Involved with Individual/ Family (include health care providers)
Example would be a Primary Care Dr., Adult Day Training Program, School, Job, Rehabilitation Agency etc.
A many as possible please. (This allows us to verify and/or obtain information needed to make a determination of eligibility).
Name of agency/program
Contact person
Phone number
Address
Name of agency/program
Contact person
Phone number
Address
Name of agency/program
Contact person
Phone number
Address
Name of agency/program
Contact person
Phone number
Address
What are your interests, talents, attributes, gifts, strengths, preferences, and communication style?
How would you best describe yourself to others?
What are you good at doing?
What activities do you enjoy most?
Who provided the information?
Future View (personal goals for the future (3-5 years).
What are a few things you want to be different in your life in the next three to five years?
Where would you like to be living and working in the future.
What will you be doing for fun?
Life Area
Think of this section as an “annual report of sorts”
Present situation (in the life areas of home, daily activities/work/school and personal/social). Include a brief functional description of : (1) capabilities, (2) daily activities, (3) interactions with others, (4) valued roles, (5) community opportunities, (6) supports and services currently being received (both paid and unpaid), (7) issues or concerns (health, challenging behaviors or situations) the person is experiencing, (8) any changes the person wants in their present situation, and (9) important relationships in the person’s life. Also include a brief summary of personal goals achieved in the past year and/or the status toward completion. (Add additional pages if needed). This summary will serve as the annual report.
Health Summary
If not mentioned before:
Who is your primary care physician and what is their address
Who are some (other) MEDICAL DOCTORS that you have seen regularly in the past or see now?
Name
Address
Phone Number
Name
Address
Phone Number
Name
Address
Phone Number
Name
Address
Phone Number
Do you have any allergies or have any other Medical Concerns?
Who helps you manage your healthcare?
What is their relationship to you?
What is their contact information?
Assistive or Adaptive Equipment:
Yes
No
Identify glasses, dentures, equipment, etc. What adaptive equipment do you use and what is it used for?
Medications?
Name of Medication
Dosage and schedule
purpose or diagnosis
any side effects?
What are they?
Personal Goals for the Upcoming Year:
What do you want to accomplish this year?
What are the most important things you want to see happen in your life?
*Support/Services Needed to accomplish the goals mentioned above. Include all natural (those who ordinarily care for you), community, and paid supports. What types of services would you need to reach your goal? In other words, if you wanted to have a job, you would need a Job Coach.
Can the Person applying for services self-medicate?
Is the person applying for services on any type of restrictive Diet or a regular diet?
Any use of dentures, hearing aids, or glasses?
Is the person applying for services Learning Impaired?
What is the name and address of the hospital where the person was born?
Self-Help Skills:
Please rate the following skills as Complete, Partial, or None. Complete means independent, and None means the person needs total help to complete the skill.
Eating
Dressing
Undressing
Toileting
Bathing
Grooming and Personal Hygiene
Please feel free to add any comment(s) about the above skills ratings.
Briefly describe Sensory Deficits: like being frightened of loud noises or bright lights.
Briefly describe Behavior Deficits or Maladaptive Behavior: like having difficulty attending social gatherings due to inappropriate touching, or not being able to handle crowds for whatever reason.
Briefly describe the Physical/emotional status of the applicant to include his/her interests/skills and interactions with others:
Briefly describe verbal ability including speech, hearing, and vision status, and his/her understanding and use of language:
Briefly describe the individual’s ability at Self Direction and Capacity for Independent Living (adult):
Briefly describe the Current Living Environment including family dynamics: Who does the person applying for services live with?
STEP #3
Send answers to destry.lebrun@gmail.com or 850-375-4790
STEP #4
Be available during the time we agreed upon in step 1.