INFORMATION FINDER FOR ADULTS WITH AUTISM IN PA SOUTHEAST REGION

Although affordable housing development for adults with autism is still an emphasis in the development of statewide services, some adults may choose to remain at home with their families and receive needed supports there. Your help to expand services statewide is needed in filling out this form. Department of Public Welfare only recognizes people that they know exist. By filling out this form, DPW will know that you will need services now or in the near future and will emphasize the need for statewide autism specific services for adults. There must be a primary diagnosis of autism/PDD/Autism Spectrum Disorder in order to be eligible.

Submit the form to ALAW at the bottom of the page by clicking the SUBMIT button. Check off at least 3 (three) substantial functional stations under Eligibility Information or you will not be eligible for waiver services.

Thank you

Roy Diamond
President

Name of person with autism
Birthdate
Address
County
Your name
Your email
Relationship
Address
Phone
Today's Date

ELIGIBILITY INFORMATION:

  
Does the person have a diagnosis of autism or PDD? yes no

If not, what is the person's diagnosis

Does the person receive SSI?		 yes no
                        ... SSDI? yes no
Is the person eligible for medicaid (has an ACCESS card)? yes no not sure
Does the person have substantial functional limitations in any of the following areas? click here for some examples (press Ctrl & click to select multiple)
Is person eligible for mental retardation (MR) services? yes no not sure
Does person receive services funded by the MR system? yes no on waiting list
If so, are services given by: a mental retardation agency | other:
If so, rate the quality of these services: good adequate poor
If so, rate the capacity of these services to address the needs of a person with autism: good adequate poor harmful
If so, amount MR system pays to provide these services each year, if known: $

Is person eligible for mental health (MH) services?

 yes no not sure
Does person receive services funded by the MH system? yes no on waiting list
If so, are services given by: a mental retardation agency | other:
If so, rate the quality of these services: good adequate poor
If so, rate the capacity of these services to address the needs of a person with autism: good adequate poor harmful
If so, amount MR system pays to provide these services each year, if known: $
CHARACTERISTICS OF AUTISM AND RELATED DISORDERS:
A. RECEPTIVE AND EXPRESSIVE COMMUNICATION: (mark all that apply)
B. SENSORY AND PERCEPTUAL DISORDERS: (mark all that apply)
Upset by, or distracted by, some: sounds visual stimuli tactile stimuli smells/tastes | other:
Seeks out: sounds visual stimuli tactile stimuli smells/tastes | other:
Eating habits: limited range of foods avoids certain foods excess of certain foods (e.g - fatty foods, salty foods) cannot tell when has eaten enough
Insists upon: completing complex routines having certain objects (beads, string) putting household items in places of his own choosing | other:
Often upset by: changes in routine starting or ending activities relocation of furniture, etc. people coming or going | other:
Coping strategies include: repetitive movements going into confined space (e.g. small closet) seeking deep pressure (piling cushions on self, jumping) pacing avoidance of looking directly at people leaving a task after a few minutes repetition of small range of favored activities repetition of narrow range of topics, questions, phrases | other:
Challenging behaviors include: self injurious behavior tantrums hitting or kicking shoving or throwing things tearing or breaking things screaming starting fires running away verbal challenges, swearing, protracted arguments obsessive/compulsive behaviors | other:
C. SOCIAL INTERACTION DISORDERS (mark all that apply)
Often acts as if unaware of, indifferent to, or unable to respond effectively to:
SELF CARE:
For each activity, indicate degree of assistance needed		  
  needs hands-on help (cannot do) needs prompts/ cues
(assistance needed)		 independent
Bathing
Dressing
Grooming
Eating
Toileting
Meal preparation
Housework
Laundry
Shopping
Walking in neighborhood
Using public transportation
Managing money
Using phone
Home chores/repairs
SELF DIRECTION: (mark only the items the person can do consistently)
CAPACITY FOR INDEPENDENT LIVING:
How long can the individual be left alone with reasonable safety? (choose one)
Would individual be able to respond reliably? (mark all that apply)
CURRENT LIVING ARRANGEMENT  
with family (parent, other relative) - relationship:  
in group home/CLA (community-based setting) -# of people:
in public or private facility (congregate setting) -#of people:
attends residential school - completion date:        
How long in current living arrangement -years:
How long can person remain in current arrangement more years:
Is person satisfied with current arrangement? yes somewhat no
CURRENT PAID SERVICES AND VOLUNTARY ACTIVITY: (Mark all that apply)
respite care - average hours per week
volunteer care giving by friends, neighbors - average hours per week
out alone around neighborhood - hours per week
day program or sheltered workshop - hours per week
in home staff supports - hours per week
employment-paid or volunteer job - hours per week
job coaching support - hours per week
lessons or therapies - times per month
out with family members - times per month
out with friends - times per month
participates in organized group activities - times per month
attends religious services, groups - times per month
PRIMARY CAREGIVER STATUS (mark all that apply)
employed (indicate FT PT) unable to work due to caregiving
others to care for: other disabled child, disabled spouse, elderly person
only caregiver in household ill health of caregiver ill health of other family members
Age of caregiver: over 50 over 60 over 70
Caregiver willing to continue? yes for 1-5 more years need help now
Caregiver level of stress: acceptable moderate severe
Other household members' level of stress: acceptable moderate severe
Financial demands due to caregiving: acceptable moderate severe
Caregiver able to "live own life": adequately somewhat not at all
DISABLED PERSON'S CURRENT STATUS (mark all that apply):
worried/anxious
angry/hostile
irritable, easily upset
bored
 lonely, wants friends
dislikes current job or day activity
dislikes current living situation
bothered by own disability
Has a medical condition (e.g. seizures)? yes no - If so, what:
Has a psych diagnosis (e.g. depression, bipolar disorder)? yes no If so, what:
Is there evidence of post traumatic stress disorder (e.g. fear of certain places, flashbacks or nightmares, emotions set off by certain triggers) yes no
Has the person received crisis intervention in the last 5 years (e.g. been hospitalized in a psych treatment facility)? yes no
Has the person been placed in a residential school or other residential program because he or she could not be managed at home? yes no
Optional: add a written statement of 100 words or less providing other information you believe significant that is not covered by this questionnaire.
ALAW has permission to share this information with the Department of Public Welfare

 

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