Information Finder for Pennsylvania Adults with Autism

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 - ALAW

Name: *

Name of Person with Autism/ASD

Birthdate:

Enter the Birthday of the Person with Autism/ASD

Address Line 1: *

Address Line 2:

Enter Street Address

County: *

County in the Commonwealth of Pennsylvania

Your Name: *

Name of Person Filling Out Form

Your E-Mail Address: *

Enter Your E-Mail Address (We will not share your address with anyone without permission)

Relationship:

Relationship to Adult with autism/ASD Listed Above

Your Address Line 1: *

Your Address Line 2:

Enter Your Mailing Address Above

Your Phone Number: *

Enter Your Contact Phone Number

Eligibility Information:

Yes

Does the person have a diagnosis of autism or PDD?

If not, what is the person's diagnosis?:

Enter Qualifying Diagnosis

SSI / SSDI / ACCESS:

Functional Limitations:

Does the person have substantial functional limitations in any of the following areas? (See Self Care Grid for some examples)

Mental Retardation:

	Yes	No	Not Sure
Is person eligible for mental retardation (MR) services?

MR Funded:

	Yes	No	On Waiting List
Does person receive services funded by the MR system?

MR Service Provider:

Mental Retardation Agency

Other

MR Provider - Other:

if "other" was chosen, enter the provider's name here.

MR Rating:

	Good	Adequate	Poor	Harmful
If so, rate the quality of these services:
If so, rate the capacity of these services to address the needs of a person with autism/ASD:

Rate the quality above, *IF* the person is receiving MR services

MH Provider Costs: $

If so, amount MH system pays to provide these services each year, if known:

Mental Health:

	Yes	No	Not Sure
Is person eligible for mental health (MH) services?

MH Funding:

	Yes	No	On Waiting List
Does person receive services funded by the MH system?

MH Service Provider:

Mental Health Agency

Other

Does person receive services funded by the MH system?

MH Provider - Other:

If "other" was chosen, please type the name of the provider.

MH Rating:

	Good	Adequate	Poor	Harmful
If so, rate the quality of these services:
If so, rate the capacity of these services to address the needs of a person with autism/ASD:

Rate the quality above, *IF* the person is receiving MH services

MR Provider Costs: $

If so, amount MR system pays to provide these services each year, if known:

Characteristics of Autism and Related Disorders

Sensory and Perceptual Disorders

Upset Other:

If Other was chosen (upset/distracted) List Here

Seeks Out Other:

If Other Was Selected (Seeks Out), please fill out here.

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

Check all that apply.

Insists Upon:

Insists Upon Other:

If "Other" was checked, please enter here

Often Upset By:

Select All That Apply

Often Upset By Other:

if "Other" was selected, please enter description here.

Coping Strategies:

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

Select all that apply

Coping Strategies Other:

If "Other" was selected, please describe here.

Challenging Behaviors (Other):

If "other" was selected, please describe here.

Social Interaction Disorders

Self Care Assessment:

	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

For each activity, indicate degree of assistance needed

Self Direction:

can make plans for the day and carry them out

can keep to a schedule, be ready on time

can make decisions

is aware of normal hazards and avoids them

gets along with others

makes realistic plans for the near future

Mark *only* the items the person can do consistently!

Capacity for Independant Living

How long can the individual be left alone with reasonable safety?:

with occasional checking during the week

8 hours or more at a time, night or day

4-8 hours during the daytime

1 to 4 hours during the day

continuous supervision needed

Choose One Only

Current Living Arrangment:

with family (parent, other relative) - relationship

in group home/CLA (community-based setting)

in public or private facility (congregate setting)

attends residential school

Choose the current living arrangements, and describe below.

Current Living Arrangement:

Describe the living arrangement above (relationship to relative / number of people in group home / completion date of schooling.)

How long in current living arrangement:

Enter the number of years (approximate) of current living arrangement.

How long can person remain in current arrangement?:

Describe (in years, approximately) how long the current arrangment can/will be in place.128

Current Satisfaction:

	Yes	No	Somewhat
Is the person satisfied with arrangement?

Rate satisfaction of current living arrangement.

Current Paid Services and Volunteer Activity

Respite Care:

Yes

Check if yes, enter number of hours below.

Respite Care Hours:

Enter the average number of hours per week.

Volunteer Care Giving:

Yes

Volunteer care giving by friends, neighbors.

Volunteer Hours:

Enter the average number of hours volunteered per week.

Out Alone:

Yes

Hours spent out alone around the neighborhood.

Out Alone Hours:

Enter the average number of hours the person is out alone in the neighborhood per week.

Day Program / Workshop:

Yes

Day Program / Workshop Hours:

Enter the average number of hours the person spends in Day Progams / Workshops

In Home Staff Support:

Yes

Does the person receive in-home staff support?

Home Staff Hours:

Enter the average number of hours each week the person receives in home staff support.

Employment (Paid or Volunteer):

Yes

Does the person work at a paid or volunteer position?

Employment Hours:

Enter the average number of hours per employment (paid and volunteer.)

Job Coaching Support:

Yes

Does the person receive job coaching?

Job Coaching Hours:

Enter the average number of hours weekly the person receives Job Coaching.

Lessons and Therapies:

Yes

Does the person receive lessons or therapies?

Lessons / Therapy Frequency:

Enter the average number of times montly the person has lessons or therapy.

Outings With Family:

Yes

Does the person have outings with Family members on a least a monthly basis?

Family Outing Frequency:

Enter the average number times per moth the person goes on family outings.

Outings With Friends:

Yes

Does the person have outings with friends on a least a monthly basis?

Friends Outing Frequency:

Enter the average number times per moth the person goes on outings with friends.

Organized Group Activities:

Yes

Does the person participate in organized group activities at least once a month?

Group Activities Frequency:

How many times a month on average does the person participate in group activities?

Religious Services:

Yes

Does the person attend organized religious worship services at least once a month?

Religous Services Frequency:

Approximately how often monthly does the person attend religious services?

Primary Caregiver Status (please mark all that apply)

Caregiver Employment Status:

	Employed Part Time	Employed Full Time	Unable to Work Due to Caregiving
Employment Status

Please enter the description that most matches the primary caregiver's employment status.

Other Caregiving Needs:

Check all that apply above.

Caregiver Age:

under 50

50 to 60

over 70

Enter the age group of the primary caregiver.

Caregiver Willing to Continue:

	Yes	for 1 to 5 more years	need help now
Is the caregiver willing to continue?

Select the choice that most matches the primary caregivers status.

Stress / Demands:

Enter the options that most match the caregiver's situation.

Caregiver Life Quality:

	adequately	somewhat	not at all
Can the Primary Caregiver "Live Own Life"

Disabled Person's Status

Disable Person's Status Data:

Mark all that apply.

Medical Condition:

Yes

Does the disable person have a medical condition (e.g. Seizures)

Medical Condtion Description:

If Yes above, please list the medical condition(s.)

Psych Diagnosis:

Yes

Does the disable person have a Pyschological Diagnosis? (e.g. depression, bipolar disorder)

Psych Diagnosis Description:

if Yes was answered above, please list the diagnos(es) here.

Psych Grid:

	Yes	No
Is there evidence of post traumatic stress disorder (e.g. fear of certain places, flashbacks or nightmares, emotions set off by certain triggers)
Has the person received crisis intervention in the last 5 years (e.g. been hospitalized in a psych treatment facility?)
Has the person been placed in a residential school or other residential program because he or she could not be managed at home?

Enter the most appropriate choice for each question above.

Comments:

Optional: You may add comments here (approximately 100 words or less) providing other information you believe significant that is not covered by this questionnaire, or with comments and questions. Avoid using certain punctuation marks if you get an error on submission of the form.

Permission: *

This box MUST be check to allow submission of the form.

	Yes	No	Don't Know
Does the person receive SSI?
Does the person receive SSDI?
Is the person eligible for medicaid (has an ACCESS card)?

	Acceptable	Moderate	Server
Caregiver Level of Stress
Other Household Member's Level of Stress
Financial Demands Due to Caregiving