INTAKE - ANNUAL - QUARTERLY TOPICS	Date
Client	Meeting Date with Client
Staff	Meeting Date with WSC
Months Covered	Qtr 3/AR	Qtr 1	Qtr 2	Qtr 4/IP
Fill in date, names, meeting dates, and the months covered for each review. Go over each topic with the individual using the specific information provided on each topic in the Reference Guide to help explain each topic to the client and ensure he understands each topic Use a check ( ) to indicate the topic has been covered or NO if the client refuses to discuss a topic. Fill in the information, when required. Provide copies, if requested. For a new client on intake, use this form and original documents with signatures.
Intake with new client?	Yes	No	Date of intake, if Yes.
Topic	Explanation
Rights, Choice, Responsibilities	Individual's rights as a US citizen and as a client in supported living, his responsibilities in supported living, and how staff will assist him to live independently. Ensure the Rights, Responsibilities, & Choice Chart is posted/available in the home.
Reporting Measures	Steps an individual can take to resolve problems, conflicts, disagreements, and issues with neighbors, friends, roommates, family, and staff, and how and when to report abuse, incidents. Ensure the Reporting Measures Chart is posted/available to the individual in his home. Ensure the client has a copy of the Grievance form, if requested.
HIPAA (CFOP 60-
17, 02-01-03)	HIPPA (Health Information Portability and Accountability Act) rights, including how and when medical information about a client may or may not be used and disclosed and how a client can get access to this information.
Due Process	Includes "fair hearings" (challenge/appeal actions relating to Medicaid services ) and "administrative hearings" (challenge actions related to services funded only by state general revenue money), when they can be requested, and process used.
Emergency Procedures	Provide the individual with brief scenarios to ensure he understands what to do in emergency situations. Include home appliances, fire, lightning storms, emergency numbers, and emergency evacuation procedures and route.
Circle of Support	Discuss and list the client's circle of support, including paid professionals, acquaintances, good friends, family, loved ones.

Key Authorization	If staff hold a house key to the individual's home (IHSS, emergency situations, etc), the individual must agree to this.
Staff (name, service) with key access:
Staffing Authorization	Qualified staff members are available to assist with progress on support plan goals, skills to meet daily needs, to improve daily living skills, to assist with medical, dental another health services, and to enrich the individual's personal and community life. There may be more than one staff person providing different services or more than one staff providing the same services. In general, there will be one main staff person to whom the individual may refer all of his questions/problems and to help coordinate services. Due to emergencies, split tasks, vacations, or other reasons, the main staff may be unavailable and may ask another qualified staff person to assume his responsibilities.
Main Staff (name, service):

Other Staff (name, service):
Financial Authorization	The individual's preference regarding his finances. Go over options to ensure client understands he can change his mind.
Provider as Representative Payee/Name:

Financial Company as Representative Payee/Name:

Family Member as Representative Payee/Name:

I am interested in exploring how to become my own representative payee.

Myself as Representative Payee

Staff Holds Money/Checkbook for Me/Name of staff:

Other (specify)	IFP

Subsidy request, if required

If provider is rep-payee, review checkbook, bills, bank statement

If a Financial Company is used, review quarterly statement, 1 bill
List Income (SSA, SSI, FS, employment, other assets)

List Debts

Bill of Rights	Bill of Rights of Individuals with Developmental Disabilities – Intake.
Functional Community Assessment	Evaluation of abilities, skills, and knowledge. Complete with the FCA Categories – Intake, Annual.
Abuse Topics	Discussion of abuse, neglect, exploitation. Complete with Abuse Topics – Intake, Annual.
Client-Guardian Release	Discussion of supported living - expectations, services, providing information - Intake, Annual.
ISSUES

Individual	Signature	Date
Client
Guardian
Staff
WSC