DADS or HHSC Form - Texas
|[pic] |Summary of Client’s Need for Service | (Auto) Form 2059 |
| | |September 2009 |
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|Client No.: | |Client Name: | |
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|Action Type: | |Assessment Date: | |
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|Conditions which cause functional limitations: |
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|Why is client unable to perform, or is limited in, activities of daily living? |
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|Description of client’s home environment: |
|Residence |Adequate | |
| In town/suburb | Home equipped with electricity, heat, water, and plumbing | |
| Rural area, easily accessible | | |
| Rural area, difficult to access |Miscellaneous | |
| Isolated | Special-equipped vehicle for transport | |
| No residence | | | |
| Other: |Assistive Devices |Other – Comments: | |
| | Ramp | | |
|Laundry | Hospital Bed | | |
| Washer and Dryer | Grab bars | | |
| Washer only | Portable toilet | | |
| Neither | Other: | |
| |
|Explanation of specific problems that impact service delivery: |
|Unsafe |Questionable | |
| Unsanitary | No water | No telephone |
| Severe state of disrepair | No plumbing/needs major repairs | Extreme clutter |
| Other: | No electricity | Dangerous pets |
| | No A/C or fan | Other: |
|Client’s Living Arrangement: |
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|Explanation of current and ongoing role of family or caregiver in meeting client’s needs: |
|Support Name |Primary Support Type |Reason Why Need of Client Cannot Be Met |
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|Common Household Task(s) being purchased and the reason: |
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|What other services is client currently receiving or being referred for? |
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|Agency(ies) Selected: |
| |Service: |Provider ID: |Provider DBA Name: |Method of Selection: |
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