Developmental Center Screening

Developmental Center Screening

Admission Criteria

State Developmental Centers provide services to individuals:

With Intellectual and Developmental Disabilities (I/DD) and complex behavioral, physical and/or medical health needs AND
Who meet the ICF/IDD level of care "IDD diagnosis and meet adaptive functioning criteria" AND
For whom the networks of community resources have been explored and appropriate community based services were not able to be identified

State Developmental Centers are intended for short term stabilization and support and used once community options have been exhausted.

If member is not receiving services and community options have not been explored, please contact our member and recipient line at 1-877-685-2415 and request assistance for resources.

Member Name*

Member DOB*

Reason for Referral or member needs*

Program Type Requested and Why*

Attempted Interventions, services, community and residential providers explored (list providers outreached and services utilized or requested)*

Outcomes Expected from admission*

Primary and Secondary Diagnoses*

Cognitive IQ*

Adaptive Scores*

If diagnosed with I/DD, did evaluation/diagnosis occur prior to age 18?*

Yes

County of Medicaid*

Select

Is member receiving services?*

Yes

Please list services, along with providers*

Referral Point of Contact (Name and Title)*

Contact Phone Number*

Phone

Contact Email

Please upload psychological evaluation for review

Drag and drop files here or

Send me a copy of my responses

Privacy Notice|Report Abuse