Case Management Assessment Template

The Case Management Assessment form is a crucial document used to gather comprehensive information about individuals seeking case management services. This form collects essential details such as consumer demographics, medical history, and preferences for home- and community-based services. Completing this assessment accurately ensures that individuals receive the appropriate support tailored to their unique needs.

Ready to get started? Fill out the form by clicking the button below.

Table of Contents

The Case Management Assessment form serves as a vital tool in the evaluation and planning of services for individuals seeking assistance through various Home- and Community-Based Services (HCBS) waivers. This comprehensive document collects essential consumer information, including personal details such as name, address, and contact information, as well as demographic data that aids in understanding the unique needs of each individual. The form outlines the basis for case management eligibility, identifying specific waivers such as the Brain Injury Waiver and the Intellectual Disability Waiver. It also emphasizes the importance of consumer choice, allowing individuals to express their preference for either HCBS or medical institutional services. By documenting interdisciplinary team consultations, financial details, and emergency contacts, the assessment provides a holistic view of the consumer's situation. Additional sections address medical and mental health diagnoses, ensuring that all relevant health information is captured. Overall, the Case Management Assessment form is designed to facilitate a tailored approach to care, ensuring that each consumer receives the appropriate support to enhance their quality of life.

Case Management Assessment Sample

Case Management Comprehensive Assessment

Form 470-4694 (Rev. 1/10)

Section A: Consumer Information

Consumer

Name: (First, M.I., Last)

Medicaid State ID#

Date Of Birth:

Current Address:

County of Residence:

County of Legal Settlement:

Home Phone:

Work Phone:

Cell Phone:

E-mail:

Assessor

Name:

Title:

Agency:

Address:

Phone:

E-Mail:

Signature

Date

Type of Assessment

Initial

Annual

Special

Demographic Change Only Date:

Discharge Date: Reason:

Basis of Case Management Eligibility

CMI MR DD BI Waiver Elderly Waiver CMH Waiver Habilitation MFP

VERIFICATION OF HCBS WAIVER CONSUMER CHOICE: Complete this section for consumers applying for HCBS Brain

Injury Waiver, Children’s Mental Health Waiver, Intellectual Disability Waiver.

Home- and Community-Based Services (HCBS)

My right to choose a Home- and Community-Based program has been explained to me. I have been advised that I may choose:

(1) Home- and Community-Based Services or (2) Medical Institutional Services.

I choose: HCBS Medical Institutional Services

Signature of Consumer or Guardian or Durable Power of Attorney for Health Care Date

Case Management Comprehensive Assessment

Consumer Name:

Form 470-4694 (Rev. 1/10)

Interdisciplinary team members consulted (including consumer):

Name Title (if applicable) Relationship to Consumer

Additional records reviewed:

Consumer Demographics

Gender: Female Male

Language:

Yes No

Speaks English

Understands English

Needs interpreter services

Comments:

Monthly Income: (Please check all that apply)

Source Amount

SSI $

SSDI $

Employment $

Other (specify): $

Comments:

Court Involvement:

Involuntary Commitment

Probation or Parole

Child in Need of Assistance (CINA)

Child Protection

Delinquency

Foster Care

Other (Identify)

None

Comments:

Case Management Comprehensive Assessment

Consumer Name:

Form 470-4694 (Rev. 1/10)

Legal decision maker: (Please check all that apply)

None Guardian Attorney-in-fact Other (Specify):

Name: (First, M.I., Last)

Address:

Home Phone:

Work Phone:

Cell Phone:

E-mail:

Co-Decision Maker (if applicable):

Guardian Attorney-in-fact Other (Specify):

Name: (First, M.I., Last)

Address:

Home Phone:

Work Phone:

Cell Phone:

E-mail:

Financial Decision Maker: (e.g. Conservator or Attorney-in-fact) No Yes (complete below)

Name: (First, M.I., Last)

Address:

Home Phone:

Work Phone:

Cell Phone:

E-mail:

Payee: No Yes (complete below)

Name: (First, M.I., Last)

Address:

Home Phone:

Work Phone:

Cell Phone:

E-mail:

Emergency Contacts:

Primary Contact

Name: (First, M.I., Last)

Relationship:

Address:

Home Phone:

Work Phone:

Cell Phone:

E-mail:

Case Management Comprehensive Assessment

Consumer Name:

Form 470-4694 (Rev. 1/10)

Secondary Contact (if applicable):

Name: (First, M.I., Last)

Relationship:

Address:

Home Phone:

Work Phone:

Cell Phone:

E-mail:

Complete This Section For Adults (Age 18 and Over)

Veteran: Yes No

Marital Status:

Never Married

Married Spouse’s Name:

Divorced

Legally Separated

Widowed

Unknown or Other – Specify

Comments:

Complete This Section For Children (Age 17 and Under)

With whom does the child live?

(If the child currently lives in a institutional setting, please make note in the comments section below.)

What are the child’s parent’s names?

Parents marital status: Married Divorced Never married

If the parent’s are not living together, what is the non-custodial parent’s name and address?

Name:

Street:

City, State, Zip:

Parent’s contact information (if different from the child’s):

Home Phone:

Work Phone:

Cell Phone:

E-Mail:

Are there siblings in the home? Yes No

Are any siblings receiving waiver services? Yes No

Are there any individuals who are not supposed to have contact with the child? Yes No

If yes, specify:

Other Comments:

Case Management Comprehensive Assessment

Consumer Name:

Form 470-4694 (Rev. 1/10)

Medical Information

Diagnoses:

Medical:

Diagnosis

Name and credential of professional making diagnosis:

Date of diagnosis:

Comments:

Mental Health (DSM-IV-TR)

Axis 1:

Axis 2:

Axis 3:

Axis 4:

Axis 5:

Name and credential of professional making diagnosis:

Date of diagnosis:

Comments:

Health Care Provider Information:

Who is your regular doctor? None

Name Address Phone

Date of last visit (if known): Reason:

Who is your regular dentist? None

Name Address Phone

Date of last visit (if known): Reason:

Are you seeing any other doctors, such as a psychiatrist, or specialists of any kind?

Yes (list below) No Don’t know

Name Specialty Address Phone

Complete this section for consumers applying for or receiving HCBS Intellectual Disability Waiver.

List the most current IQ score, or if the IQ isn’t listed, give the consumer’s level of functioning within the range of mental

retardation (mild, moderate, severe, profound):

IQ: Range: Date of Evaluation:

Complete this section for consumers applying for or receiving HCBS Brain Injury Waiver.

Diagnosis: Date Injury Occurred:

Case Management Comprehensive Assessment

Form 470-4694 (Rev. 1/10)

Section B: Medical and Physical Health

Health Conditions

B1. Overall, how would you rate your physical health?

Excellent Good Fair Poor No Response

Comments:

B2. Do you have any health problems that require assistance to manage?

Cardiac

Skin Related

G.I. Disorders

Urinary Tract

Weight problems

Evidence of communicable disease

Other – Specify

None

How do they affect you and how long have you had them?

Comments:

B3. Any respiratory problems that require assistance to manage?

Ventilator

Oxygen

Suctioning

Tracheotomy

Cardiorespiratory monitor

Chest physiotherapy

Nebulizer treatment

Other – Specify

None

How do they affect you and how long have you had them?

Comments:

B4. Do you regularly receive any of the following medical treatments?

Days per week Hours per day

Nursing no yes

Physical Therapy no yes

Occupational Therapy no yes

Speech Therapy no yes

Supervision for Safety no yes

Diabetes Education no yes

Dialysis no yes

Respiratory Treatment no yes

Catheter Care no yes

Colostomy Care no yes

Nasogastric Tube Care no yes

Other no yes

Case Management Comprehensive Assessment

Consumer Name:

Form 470-4694 (Rev. 1/10)

B5. Hearing

No hearing impairment.

Hearing impairment, but managed through assistive devices

Hearing difficulty at level of conversation.

Hears only very loud sounds.

No useful hearing.

Not determined.

Comments:

B6. Vision

Has no impairment of vision.

Vision impairment, but managed through assistive devices

Has difficulty seeing at level of print (far-sighted).

Has difficulty seeing obstacles in environment (near-sighted).

Has no useful vision.

Not determined.

Comments:

B7. Speech/Communication

Communicates independently or impairment has been compensated to function independently.

Communicates with difficulty but can be understood.

Communicates with sign language, symbol board, written messages, gestures or an interpreter.

Communicates inappropriate content, makes garbled sounds, or displays echolalia.

Does not communicate.

Comments:

B8. Sensory Perception (e.g. – taste, smell, tactile, spatial)

No impairment

Impaired – Specify

Comments:

B9. Cognitive Status

Alert and fully oriented

Alert and oriented with significant alteration on self-concept/mood

Generally oriented through use of assistive techniques

Cognitive deficits (e.g. orientation, attention/concentration, perception, memory, reasoning)

Exhibits mental status changes consistent with psychiatric disorder

Comatose, but responsive

Comatose, but unresponsive

Other – Specify

Comments:

B10. Musculoskelatal/Fine or Gross Motor Skills

No Impairment of Musculoskelatal/Fine or Gross Motor Skills

Impaired muscle tone

Contractures

Scoliosis

Paralysis: Hemiplegia Paraplegia Quadriplegia Other (Specify)

Comments:

Case Management Comprehensive Assessment

Consumer Name:

Form 470-4694 (Rev. 1/10)

Complete This Section For Adults (Age 18 and Over)

B11. Do you have someone who could stay with you for a while if you were sick or needed help?

Yes (Complete below) No

Name: Relationship:

Address:

City, State, Zip code:

Phone:

B12. Is there anybody you would not want to be involved with your care if you were sick or needed help?

Yes (Complete below) No

Name: Relationship:

HEALTH CONDITIONS RISK FACTORS YES NO

R1. Has the consumer had a seizure in the past year?

R2. Does the consumer have a diagnosis of any other serious medical conditions or other serious health

concerns (i.e., diabetes, cerebral palsy, heart condition, etc.)?

If yes, list all conditions/concerns:

R3. Does the consumer have any life threatening allergies (such as peanuts, bee stings, or shellfish)?

R4. Is the consumer in need of a primary health care provider (or the provider’s contact information is

unknown)?

R5. Is the consumer in need of a dentist (or dentist’s contact information is unknown)?

R6. Is the consumer in need of a specialist (or the specialist’s contact information is unknown)?

R7. Has the consumer had difficulty making, keeping, or following through with appointments in the last year?

R8. In the past year, has the consumer gone to a hospital emergency room?

If yes, how many times? Why?

R9. In the past year, has the consumer stayed overnight or longer in a hospital?

If yes, how many times? Why?

R10. Is the consumer in need of someone to help if he or she was sick or injured?

Comment on any risk factors marked as “Yes” and address the issue in the Crisis Intervention Plan.

Comments:

No. of risks:

Case Management Comprehensive Assessment

Consumer Name:

Form 470-4694 (Rev. 1/10)

Medication Use

B13. Are you currently taking any prescription medication? Yes (complete below) No

Medication Name Dosage Frequency Purpose

Comments:

B14. Are you currently taking any over-the-counter medications on a regular basis (pain relievers, vitamins, laxatives, etc.)?

Yes (complete below) No

Medication Name Dosage Frequency Purpose

Comments:

Case Management Comprehensive Assessment

Consumer Name:

Form 470-4694 (Rev. 1/10)

Complete this section only if the consumer is taking medications.

B15. Are any of your medications kept in a special place, like a locked container or the refrigerator?

Yes No

Comments:

B16. What pharmacy do you use?

B17. How do you remember to take your medications? (Check all that apply.)

By following directions Calendar RN Set-up

Caregiver gives them Bubble wrap/Blister Pack Pill Minder

Medpass Machine Egg Carton, envelopes Other:

Comments:

B18. How well do you self-administer medication?

With no help or supervision

With some help or occasional supervision

With a lot of help or constant supervision

Unable to administer own medications/caregiver gives them

Comments:

MEDICATION ERROR RISK FACTORS

3 = Frequently 2 = Sometimes 1 = Rarely 0 = Never

YES

3 2 1 0

R11. Has the consumer had problems with not taking or not receiving medications on time?

R12. Has the consumer had problems with taking or being given the incorrect number of

medications?

R13. Has the consumer had problems with medications not being refilled on time?

R14. Have there been issues with medications not being re-evaluated timely?

R15. Has the consumer had significant side effects from medications?

R16. Has the consumer had significant medication changes in the past year?

R17. Has the consumer refused or spit out medications?

R18. Have there been problems with drug interactions?

R19. Has the consumer experienced health problems because of missing/refusing

medications?

R20. Has the consumer misused prescription or over-the-counter medications (i.e., taken too

many at once)?

R21. Has the consumer taken another person’s prescription medications?

R22. Has the consumer used out-dated medications?

R23. Has the consumer used multiple pharmacies or multiple physicians in the past year?

Comment on any risk factors marked as “Yes” and address the issue in the Crisis

Intervention Plan.

Comments:

No. of risks:

▼ Case Management Assessment PDF Form

Document Attributes

Fact Name	Description
Purpose	The Case Management Assessment form is designed to gather comprehensive information about consumers to determine eligibility for various case management services.
Consumer Information	Section A collects essential details such as the consumer's name, address, date of birth, and contact information to ensure accurate identification and communication.
Assessment Types	The form allows for different types of assessments, including initial, annual, and special assessments, catering to the changing needs of consumers.
HCBS Waiver Choices	Consumers applying for Home- and Community-Based Services (HCBS) must indicate their choice between HCBS and medical institutional services, ensuring informed decision-making.
Demographic Data	Demographic information such as gender, language proficiency, and income sources is collected to tailor services to the consumer's unique circumstances.
Legal Decision Makers	The form identifies legal decision makers and emergency contacts, which is crucial for communication and decision-making in case of emergencies.
Governing Laws	In many states, including Iowa, the use of this form is governed by regulations pertaining to Medicaid and HCBS waivers, ensuring compliance with state and federal laws.

Case Management Assessment: Usage Instruction

After completing the Case Management Assessment form, it will be submitted to the appropriate agency for processing. This form collects important information that will assist in determining the necessary case management services for the consumer.

Begin with Section A: Consumer Information. Fill in the consumer's name, current address, Medicaid State ID#, date of birth, and county of residence.
Provide the home phone, work phone, cell phone, and email address of the consumer.
Enter the assessor's name, title, agency, address, phone number, and email address. Sign and date the form.
Indicate the type of assessment by checking the appropriate box: Initial, Annual, Special, or Demographic Change Only. Also, fill in the date and discharge date if applicable, along with the reason for discharge.
In the Basis of Case Management Eligibility section, check all applicable options: CMI, MR, DD, BI Waiver, Elderly Waiver, CMH Waiver, Habilitation, or MFP.
For HCBS Waiver Consumer Choice, indicate whether the consumer has been informed about their choice between Home- and Community-Based Services or Medical Institutional Services. Have the consumer or their guardian sign and date this section.
List the interdisciplinary team members consulted, including their names, titles, and relationship to the consumer.
Review additional records if applicable and provide comments as necessary.
Complete the Consumer Demographics section by indicating gender, language proficiency, and whether interpreter services are needed. Also, provide monthly income sources and amounts.
In the Court Involvement section, check any relevant boxes and add comments as needed.
Identify the legal decision maker by checking the appropriate box and providing their name and contact information.
If applicable, list the co-decision maker and financial decision maker, including their names and contact details.
Provide emergency contact information for the primary and secondary contacts, including their names, relationships, and contact details.
For adults, indicate veteran status and marital status. For children, specify with whom the child lives, parents' names, and any relevant details about siblings.
In the Medical Information section, list any diagnoses and the names of professionals who made those diagnoses, including dates and comments.
Complete sections specific to the HCBS Intellectual Disability Waiver and HCBS Brain Injury Waiver if applicable, providing IQ scores and health care provider information.

Frequently Asked Questions

What is the purpose of the Case Management Assessment form?

The Case Management Assessment form is designed to gather essential information about a consumer's needs and circumstances. This information helps case managers provide appropriate services and support. It ensures that the consumer receives the right type of care and assistance based on their unique situation.
Who needs to complete this form?

This form is typically completed by the consumer or their legal representative. If the consumer is a child, a parent or guardian will fill it out. The assessor, who is a trained professional, will also be involved in the process to ensure all necessary information is collected accurately.
What information is collected in the form?

The form collects various types of information, including:
- Consumer's personal details, such as name, address, and contact information.
- Demographic information, including age, gender, and language needs.
- Medical and mental health history, including diagnoses and treatment details.
- Financial information, such as income sources and amounts.
- Emergency contact information for family or friends.
How is the information used?

The information collected helps case managers understand the consumer's needs. It assists in determining eligibility for various programs and services. The data is also used to create a personalized care plan that addresses the consumer's specific requirements.
Is the information confidential?

Yes, the information provided in the Case Management Assessment form is confidential. It is protected by privacy laws and regulations. Only authorized personnel will have access to this information, ensuring that the consumer's privacy is respected at all times.
What should I do if I need assistance completing the form?

If you need help with the form, reach out to your case manager or the agency providing the assessment. They can guide you through the process and answer any questions you may have. It's important to ensure that all sections are completed accurately to facilitate the best possible care.
What happens after the form is submitted?

Once the form is submitted, the case manager will review the information. They may contact you for additional details if needed. After the assessment, a care plan will be developed based on the consumer's needs, ensuring they receive the appropriate support and services.

Common mistakes

Filling out the Case Management Assessment form can be a straightforward process, but common mistakes can lead to complications. One frequent error is omitting essential consumer information. This includes the consumer's name, date of birth, and current address. Incomplete sections can delay the assessment process and may result in the need for additional follow-up.

Another mistake involves failing to accurately indicate the type of assessment being conducted. The form requires a selection between initial, annual, or special assessments. If this section is left blank or incorrectly filled out, it can lead to confusion about the purpose of the assessment and hinder appropriate service delivery.

People often overlook the verification of Home- and Community-Based Services (HCBS) consumer choice. It is crucial to ensure that the consumer's choice is clearly marked and that the signature of the consumer, guardian, or durable power of attorney is obtained. Without this verification, the application for HCBS may be deemed invalid.

Inaccuracies in reporting income sources can also create issues. The form asks for details about monthly income, including specific amounts from various sources. If these figures are not provided or are incorrect, it can affect eligibility determinations and the services that may be available to the consumer.

Lastly, neglecting to provide emergency contact information can be a significant oversight. The form requires details for primary and secondary contacts. Missing this information can complicate communication during emergencies and may hinder timely responses to the consumer's needs.

Documents used along the form

The Case Management Assessment form is a critical document used in evaluating the needs of individuals seeking case management services. It helps to gather comprehensive information about the consumer, their circumstances, and their support systems. Alongside this form, several other documents are commonly utilized to ensure a complete understanding of the consumer's situation and to facilitate appropriate service delivery.

Individualized Service Plan (ISP): This document outlines the specific goals and services tailored to the consumer's needs. It serves as a roadmap for the case management process.
Authorization for Release of Information: This form allows the case manager to obtain necessary information from other agencies or individuals, ensuring compliance with privacy regulations.
Medical History Form: This form collects detailed medical information about the consumer, including past diagnoses, treatments, and current medications, which is essential for informed case management.
Eligibility Determination Form: Used to assess whether the consumer meets the criteria for specific programs or services, this form is crucial for accessing benefits.
Progress Notes: These notes document ongoing interactions and developments in the consumer's case, providing a record of services provided and any changes in circumstances.
Emergency Contact Form: This document lists individuals to contact in case of an emergency, ensuring that the consumer's needs are met promptly.
Client Consent Form: This form secures the consumer's consent for participation in services and acknowledges their understanding of the process.
Referral Form: This document is used to refer the consumer to additional services or specialists as needed, facilitating comprehensive care.
Assessment Summary Report: This report synthesizes findings from the assessment process, summarizing key information and recommendations for service delivery.
Discharge Summary: Upon completion of services, this document outlines the consumer's progress, outcomes, and any follow-up recommendations, ensuring continuity of care.

These documents work together to create a holistic view of the consumer's needs and circumstances, enhancing the effectiveness of case management services. Proper documentation not only supports service delivery but also ensures that consumers receive the care and support they deserve.

Similar forms

Intake Form: Similar to the Case Management Assessment form, an intake form gathers essential consumer information at the beginning of a service relationship. It typically includes personal details, contact information, and service needs.
Client Assessment Tool: This document evaluates a client’s needs, strengths, and challenges. Like the Case Management Assessment, it aims to create a comprehensive understanding of the individual to tailor services accordingly.
Service Plan: A service plan outlines the specific goals and interventions for a consumer. It mirrors the Case Management Assessment in its focus on individual needs and preferences, ensuring that services align with the consumer's choices.
Eligibility Determination Form: This form assesses whether a consumer qualifies for specific programs or services. It shares similarities with the Case Management Assessment in verifying eligibility based on defined criteria.
Health History Form: A health history form collects detailed medical information. Like the Case Management Assessment, it emphasizes the importance of medical background in determining appropriate care and services.
Consent Form: This document secures a consumer's agreement for services. It is akin to the Case Management Assessment in that it ensures consumers are informed and have the right to make choices regarding their care.
Progress Notes: Progress notes document ongoing consumer interactions and developments. They are similar to the Case Management Assessment in tracking changes and ensuring continuity of care over time.
Discharge Summary: A discharge summary provides a comprehensive overview of a consumer's journey and outcomes. It parallels the Case Management Assessment by summarizing key information and decisions made during the service period.

Dos and Don'ts

When filling out the Case Management Assessment form, it is essential to approach the task with care and attention to detail. Here is a list of things you should and shouldn't do:

Do ensure that all consumer information is accurate and complete, including names, addresses, and contact details.
Do verify that the consumer's choice regarding Home- and Community-Based Services (HCBS) is clearly documented.
Do consult with interdisciplinary team members to gather comprehensive insights about the consumer.
Do review any additional records that may provide relevant information about the consumer’s situation.
Don't skip sections of the form; each part is crucial for a thorough assessment.
Don't use abbreviations or shorthand that could lead to confusion; clarity is vital.
Don't forget to sign and date the form upon completion, as this confirms the information provided.
Don't leave any questions unanswered unless they are not applicable; this could delay the assessment process.

By adhering to these guidelines, you can help ensure that the assessment process is efficient and effective, ultimately benefiting the consumer's care and support.

Misconceptions

Misconceptions about the Case Management Assessment form can lead to confusion and misinterpretation. Below are ten common misconceptions, along with explanations to clarify each one.

It is only for individuals with disabilities. The form is designed for a variety of consumers, including those who may not have a disability but require case management services.
Only medical professionals can fill it out. While medical professionals often contribute, the form can be completed by any qualified assessor or case manager.
It is a one-time assessment. The form can be used for initial assessments as well as annual reviews or special circumstances, indicating that it is not limited to a single use.
All sections must be filled out completely. Some sections may not apply to every consumer, and it is acceptable to leave those sections blank.
It only collects medical information. The form gathers a wide range of information, including demographic, financial, and social details, not just medical data.
It is only for adults. The form includes sections specifically tailored for children, ensuring it accommodates consumers of all ages.
Signature is not necessary. A signature from the consumer or their legal representative is required to validate the assessment and ensure informed consent.
It is a lengthy and complicated process. While it may seem detailed, the structure of the form is designed to streamline the assessment process for both the assessor and the consumer.
Case management eligibility is determined solely by the form. The form is a tool to gather information; eligibility is assessed based on a combination of factors, including but not limited to the information provided.
Once submitted, the information cannot be updated. Consumers can update their information at any time, especially if there are significant changes in their circumstances.

Key takeaways

Filling out the Case Management Assessment form is an important step in ensuring that consumers receive the appropriate support and services. Here are some key takeaways to keep in mind:

Accuracy is Essential: Ensure all information provided is correct and up-to-date. Inaccurate details can lead to delays in receiving services.
Consumer Choice Matters: Clearly indicate whether the consumer prefers Home- and Community-Based Services or Medical Institutional Services. This choice is vital for tailoring care.
Complete All Sections: Fill out every section of the form, including demographics, medical information, and emergency contacts. Missing information can hinder the assessment process.
Involve the Right People: Consult with the consumer and any relevant interdisciplinary team members. Their input is crucial for a comprehensive assessment.
Document Financial Information: Provide accurate monthly income details. This helps in determining eligibility for various programs and services.
Keep Copies: After completing the form, retain a copy for your records. This can be helpful for future assessments or if any questions arise.

Following these guidelines will help ensure a smooth process when using the Case Management Assessment form. Properly completed forms lead to better outcomes for consumers in need of assistance.