Illinois Department of Human Services - Division of ...



Illinois Department of Human Services ● Division of Developmental Disabilities

Determination of Behavioral Needs Questionnaire - Page 1 of 3

Instructions: Use this form to request additional direct staff supports (53R and/or 53D) in order to address behavioral needs of individuals who receive Community Integrated Living Arrangement (CILA), Developmental Training (DT), or Adult Home-based Support (AHBS) services only. The Division of Developmental Disabilities (DDD) will consider authorizing additional direct staff supports based on the individual’s behavioral needs only when this completed form and all supporting documentation reflecting the individual’s needs are submitted to your Network Facilitator.

______________________________________________________________ ________________

Name of Agency Requesting Additional/Enhanced Staff Support Agency ID #

DHS/DDD Network of Requesting Agency:

[ ] Northwest [ ] Central [ ] Metro No. Suburbs [ ] Metro Chicago

[ ] No. Central [ ] Southern [ ] Metro So. Suburbs

Individual’s Name: __________________________________________________________________________

Address of Individual: ________________________________________________________________________

City: _____________________________ Zip Code: _______________ DOB: ____________________

S. S. Number: ________ - _______ - ________ RIN: __________________________

This Staff Add-On Request is for: (Check Only One)

Community Integrated Living Arrangement (CILA) Setting

Initial request for 53R Temporary Intensive Staff Support (348 hours)

Subsequent request for 53R funding (348 hours). Previous dates(s) of 53R: ______________________

A Staff Add-On request to be included in the person’s 60D CILA residential rate.

Developmental Training (DT-31U) Setting

Initial request for 53D Temporary Intensive Staff Support (115 hours)

Subsequent request for 53D Funding (115 hours). Previous dates(s) of 53D: ______________________

A Staff Add-On request to be included in the person’s 31U Developmental Training rate.

Adult Home-Based Support (AHBS), only applicable for 53D - Development Training Setting – 31U

Current Service Agreement that indicates 53D funding will be deducted from the individual’s monthly AHBS

allotment (Service Agreement must be signed by Individual/Legal Guardian and Service Facilitator).

Identify the Primary Residential, Developmental Training and/or HBS Service Provider(s) currently (or will be) authorized for this person. Identify the Primary Provider(s) by Name. (Check and Complete All That Apply)

Does this person receive any residential supports? No Yes - DD Residential Program Code: ______

If yes, residential provider’s name: __________________________________________________________________

Does this person receive day program supports? No Yes - DD Day Program Code: ______

If yes, day program provider’s name: ________________________________________________________________

Does this person receive Adult Home-Based Support services? No Yes

If yes, AHBS service facilitator agency’s name: ________________________________________________________

Illinois Department of Human Services ● Division of Developmental Disabilities

Determination of Behavioral Needs Questionnaire - Page 2 of 3

Individual’s Name: _________________________________________________________________________

Identify the behavior(s) that form the basis of this request. Indicate the number of behavioral occurrences for each of the previous 3 months beginning with the most recent month for all that apply (numerical values only):

Current Month 1 Month Prior 2 Months Prior

Residential/DT Residential/DT Residential/DT

Aggression - Verbal _____/_____ _____/_____ _____/_____

Aggression - Physical _____/_____ _____/_____ _____/_____

Criminal Activity _____/_____ _____/_____ _____/_____

Specify: ______________________________________________________________________________________

Elopement _____/_____ _____/_____ _____/_____

Fire Setting _____/_____ _____/_____ _____/_____

Hoarding _____/_____ _____/_____ _____/_____

PICA _____/_____ _____/_____ _____/_____

Property Destruction _____/_____ _____/_____ _____/_____

Self Injurious Behavior _____/_____ _____/_____ _____/_____

Sexual Exposure/Acting Out _____/_____ _____/_____ _____/_____

Other Behavior(s): _____/_____ _____/_____ _____/_____

Specify: ________________________________________________________________________________________

Each behavior identified above with frequency data must have a separate Behavior Description Form completed and attached to this request.

Required Attachments: (Packet will be returned if not complete)

1. Narrative that clearly explains why the individual requires 1:1 staff support with a description of the duties and responsibilities of the 1:1 staff; and

2. Current and proposed staff schedules that show the staff on duty and times requested for 1:1 direct staff support for the person; (Required if requesting add-on included in the individual’s rate); and

3. Completed Behavior Description Form for each behavior identified above; and

4. Current Behavior Program (completed or updated within the past 6 months); and

5. Current Individual Service Plan (ISP) and any related special IDT/CST notes; and

6. Fading plan to reduce or eliminate additional staff support, which includes the criteria to start fading;

7. Current ICAP or SIB; and

8. Functional Assessment/Analysis (If available for temporary staff add-on;

Required if requesting add-on included in the individual’s rate); and

9. Consultation Reports from a Behavior Analyst, Psychiatrist, Psychologist, etc. (As applicable); and

10. Copies of at least the 2 most recent ISSA visit notes; and

11. CART & SST Considerations and Implementation Results (If available for temporary add-on;

Required if requesting Add-on included in the individual’s rate); and

12. Monthly Behavioral Data in graph form that includes, at least, the past 3 months.

Signature(s):

___________________________________ ___________ _____________________________ __________

Residential Provider Signature, or Date PAS/ISC Agency’s Signature Date

Day Program Provider Signature, or

HBS Service Facilitator Signature (Check which apply)

___________________________________________________ ____________________________________________________

PRINT Name of Residential/DT/HBS Provider Contact PRINT Name of PAS/ISC Agency Contact

(_____) ____________________________________________ (______) _____________________________________________

Residential/DT/HBS Contact Phone Number Ext. PAS/ISC’s Contact Phone Number Ext.

Illinois Department of Human Services ● Division of Developmental Disabilities

Determination of Behavioral Needs Questionnaire - Page 3 of 3

DHS-DDD USE ONLY - Internal Network Recommendation for a Behavioral Needs Request

Individual’s Name: _______________________________________________________________________

Required Attachments: (Network staff must check each attachment received with request)

1. Narrative that clearly explains why the individual requires 1:1 staff support with a description of the duties and responsibilities of the 1:1 staff; and

2. Current and proposed staff schedules that show the staff on duty and times requested for 1:1 direct staff support for the person; (Required if requesting add-on included in the individual’s rate); and

3. Completed Behavior Description Form for each behavior identified above; and

4. Current Behavior Program (completed or updated within the past 6 months); and

5. Current Individual Service Plan (ISP) and any related special IDT/CST notes; and

6. Fading plan to reduce or eliminate additional staff support, which includes the criteria to start fading;

7. Current ICAP or SIB; and

8. Functional Assessment/Analysis (If available for temporary staff add-on;

Required if requesting add-on included in the individual’s rate); and

9. Consultation Reports from a Behavior Analyst, Psychiatrist, Psychologist, etc. (As applicable); and

10. Copies of at least the 2 most recent ISSA visit notes; and

11. CART / SST Considerations and Implementation Results (If available for temporary add-on;

Required if requesting add-on included in the individual’s rate); and

12. Monthly Behavioral Data in graph form that includes, at least, the past 3 months.

Residential Provider’s Name: __________________________________________________________________________

____ Recommend a Temporary INITIAL 53R award for Residential supports. Effective Date: ____________

____ Recommend a Temporary SUBSEQUENT 53R award for Residential supports. Effective Date: ______

____ Recommend a Staff Add-On of ______ hours/per week day [Monday–Friday] to be included in this person’s Residential Rate. Note: Nine (9) hours/ per-week day would equal 1:1 for all paid awake hours

____ Recommend a Staff Add-On of _____ hours/weekend [Saturday-Sunday] to be included in this person’s Residential Rate. Note: Sixteen (16) hours/weekend day would equal 1:1 for all paid awake hours.

Developmental Training (DT) Provider’s Name: ___________________________________________________________

____ Recommend a Temporary INITIAL 53D award for DT. Effective Date: ____________________________________

____ Recommend a Temporary SUBSEQUENT 53D award for DT. Effective Date: _______________________________

____ Recommend a Staff Add-On of _____ hours /day for DT to be included in this person’s 31U Rate.

Note: Maximum recommendation may not exceed 5 hours/day in a Program 31U DT setting.

____ Incomplete Request – return to Requesting Agency Date: ___________________________________________

____ Deny the 1:1 Staff Support Request – Behaviors and Documentation does not support the request. The Network Facilitator/BTS Representative will communicate the reason for a denial to the requesting agency and ISSA.

____ Deny the 1:1 Staff Support Request – Alternative resources and behavior management methods should be implemented before further consideration of a 1:1 Staff Support Request. The Network Facilitator/BTS Representative will communicate the reason for a denial to the requesting agency and ISSA.

___________________________________________ __________________________ ________________________

Network Facilitator/BTS Representative’s Signature Date DHS/DDD Track-It Number

G:\Community-Services\BCR\CILA\Behavioral Form 2-16-12.doc Revised 02/16/2012

Illinois Department of Human Services ● Division of Developmental Disabilities

Determination of Behavioral Needs Questionnaire

Behavior Description Form - Page 1 of 2

Individual’s Name: _______________________________________________________________________

*Use a Separate Behavior Description Form for Each Identified Behavior & Location*

Behavior (Any activity a person does that is observable and measurable):

___________________________________________________________________________________________________

___________________________________________________________________________________________________

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Specify and identify the time(s) of day and specific location(s) this behavior most often occurs: (Include frequency- how often it occurs per hour, day, week, or month; and duration-how long it lasts when it occurs) ___________________________________________________________________________________________________

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In regard to the behavior listed above, describe the intensity (specify the damage, destruction, and/or disruption caused by the behavior), severity (what is the adverse outcome(s) of this behavior), and consequences (what happens when the behavior occurs, what does the individual get out of the situation, does the individual get what they want?).

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Describe any recent significant life changes in this person’s life such as medical conditions, new residential and/or day program settings, loss of relative, staff changes, etc.:

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Illinois Department of Human Services ● Division of Developmental Disabilities

Determination of Behavioral Needs Questionnaire

Behavior Description Form - Page 2 of 2

Individual’s Name: _______________________________________________________________________

Behavior (Any activity a person does that is observable and measurable):

___________________________________________________________________________________________________

___________________________________________________________________________________________________

Identify strategies, interventions, and/or recommendation(s) for any consultation services and/or behavioral supports that have been used to address the behavior(s) identified above such as: Behavioral Intervention (56), CART, Consult with Network and/or SODC staff, Counseling (57U/G), Medical Specialists, Primary Care Physician, Psychiatrist, Psychologist, Technical Assistance, and/or Therapy (58U/G) ___________________________________________________________________________________________________ ___________________________________________________________________________________________________

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Identify any challenges to implementing the behavior strategies, interventions, and/or recommendation(s). (Please refer to the attached Behavioral Intervention Definitions pages 1 and 2). Also, provide the name/contact information of the Behavioral Support Professional_______________________________________________________________________

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Describe in detail the duties and responsibilities of the Temporary Intensive Staff Support person or additional staff support person:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

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G:\Community-Services\BCR\CILA\Behavioral Form.doc Revised 02/16/2012

Determination of Behavioral Needs Definitions - Page 1 of 2

Behavior Contract - A procedure in which the individual served makes a contract with another individual (staff, family), to meet a pre-defined behavioral criteria, upon which a special reinforcing event is provided.

Behavior Intervention Program- A formal document that describes procedure to modify dysfunctional or problem behavior(s) and replace them with ones that are adaptive and socially appropriate.

Blocking - Preventing the occurrence of a maladaptive behavior by interposing with a protective pad or with one's own limb(s) or body.

Counseling - A talk-based therapy that focuses on helping a person understand, think about, or act upon life stressors in more adaptive ways.

De-escalation - A procedure for managing defined maladaptive behavior/s (or "precursor" behaviors) by providing the individual with redirection and supportive prompts designed to facilitate relaxation, or to elicit a positive emotional response. The intent of this procedure is to assist the person in coping with the emotional/behavioral aspects of the immediate situation. Staff demeanor should reflect patience, concern and caring. Staff may inquire as to the cause for agitation, or suggest activities, such as practiced relaxation; but the individual is allowed voluntary choice of activity, location and duration. This set of procedures represents the least-intrusive manner of dealing with individuals who are upset, provided it does not reinforce the problem behavior.

Exclusionary Time-out - Removing the individual from a reinforcing ongoing activity to a location where he/she is unable to participate or observe other individuals engaged in the activity. Exclusionary time-out includes: removal from room; removal to another room; non-locked time-out room.

Fading - Fading is the term used to label a procedure of gradually changing a stimulus, reinforcer or contingency that initially supports a targeted response, to a different stimulus, reinforcer or contingency. Fading is used to transfer a response from one set of controlling conditions to another without loss or alteration of the quality of the response. It is frequently used as a tool for transferring a newly developed response from artificially imposed conditions to those normally available in the environment of the individual.

Mobility Restriction - A procedure in which the individual's movement is restricted because of a maladaptive behavior. This procedure does not apply to mobility restrictions associated with the provision of supervision due to skill deficits, cognitive difficulties, and/or medical issues, nor to encouragement provided individuals to participate in an activity in a specific location.

Non-Exclusionary Timeout from Positive Reinforcement - Withdrawing the opportunity to earn positive reinforcement or loss of access to positive reinforcers for a specified period of time, contingent upon the occurrence of a behavior, while the individual remains in the same environment. Examples include contingent observation, planned ignoring, time-out ribbon, and withdrawal of access to a specific reinforcer. The individual may be physically separated from ongoing activities.

One-to-One Staff Supervision - The assignment of a staff member to one individual beyond 2 weeks to modify or manage maladaptive behavior(s).

Physical Response Interruption - Use of the least amount of physical contact necessary to stop an individual from engaging in a maladaptive behavior. This is done by briefly (less than approximately 15 continuous seconds) holding an individual's limbs or body.

Police Intervention - Situations or incidents where the police have been involved but that have not resulted in an arrest or criminal charges being filed.

Determination of Behavioral Needs Definitions - Page 2 of 2

Positive Reinforcement - The process of providing an item or activity immediately contingent upon the occurrence of a behavior that increases the probability of the behavior's occurrence over time. Reinforcer is the item/activity presented; reinforcement is the process.

Problem Solving - A procedure that calls for the individual and staff to develop appropriate strategies for resolving problem situations and. This involves discussing alternative responses that may occur in the future.

Psychotropic Medication - Medication to alter mood, cognition, or behavior. Medications used to control seizures, although psychoactive, are not included unless at the level required for mood stabilization or behavioral control exceeds that which is required for seizure management.

Redirection - Staff direct the individual to another activity or behavior.

Relaxation Training - Procedures designed to teach an individual to calm himself/herself, usually by having them doing some combination of breathing exercises voluntarily, going to a calm environment, doing progressive muscle relaxation, listening to relaxing music or biofeedback. These coping skills may later be employed by the individual during times of stress.

Required Relaxation - A form of exclusionary time-out wherein the individual is required to adopt a relaxed posture (sitting or lying) contingent on the target behavior. If physical assistance is required it may constitute holding restraint.

Restraint - Restriction of free movement of, normal functions of, or normal access to, a portion(s) of an individual's body.

Restitution - A procedure requiring an individual to repair or restore a damaged area or object to original condition a damaged area or object. This procedure is typically employed as response to behaviors such as throwing furniture, writing on walls, otherwise defacing or damaging property. The individual may be required to apologize, replace the stolen article, or otherwise demonstrate socially responsible behaviors that make up for the loss caused by the behavior.

Restriction of Personal Property - The time-limited removal of an individual's personal property contingent upon a target behavior.

Restriction of Visitors or Telephone Calls - A procedure in which visitors or telephone calls are limited contingent on target behavior.

Timeout - Removal of the opportunity to earn positive reinforcement.

Timeout Room - A room from which egress is able to be prevented by means of a locking device that requires constant physical pressure to engage. The room must be safe, free of electric outlets and other hazards, and provide adequate space and ventilation.

Day Program Suspension or Termination - Suspending or terminating a person from his/her regularly scheduled day program setting for a specified period of time, following the occurrence of a maladaptive behavior, based on pre-determined individualized criteria.

G:\Community-Services\BCR\CILA\Behavioral Form.doc Revised 02/16/2012

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