"Options Counseling Referral Information Form" - Colorado

Options Counseling Referral Information Form is a legal document that was released by the Colorado Department of Health Care Policy and Financing - a government authority operating within Colorado.

Form Details:

  • Released on December 1, 2017;
  • The latest edition currently provided by the Colorado Department of Health Care Policy and Financing;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Colorado Department of Health Care Policy and Financing.

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Options Counseling Referral Information Form
Date Referral Received:
ADRC Region/ILC Responding to Referral:
Referral Type: ☐ Self
☐ MDS Section Q
☐ Family/Friend
☐ Ombudsman/Advocate
☐ Other:
Nursing Facility:
Contact Name:
Phone:
Email:
Resident Information
Name:
Nickname:
Date of Birth:
Guardian Name
:
(if applicable)
Guardian Phone:
Check all that apply: ☐ Elderly
☐ Behavioral Health
☐ Physical Disability
☐ Intellectual Disability
Health First Colorado Eligible: ☐ Yes ☐ No ☐ Pending
Health First Colorado ID#:
If Health First Colorado eligible, Long-Term Care eligible: ☐ Yes
☐ No
☐ Unsure
Nursing Facility admission date:
Rehab stay: ☐ Yes
☐ No
☐ Unsure
Physician Name:
Phone:
Desired Housing Type: ☐ Apartment ☐ House
☐ Group Home ☐ Host Home
☐ Assisted Living Facility
Desired Transition Location:
Do you have a home to return to?
☐ Yes
☐ No
Is accessible housing required? ☐ Yes ☐ No
Do you require affordable housing? ☐ Yes
☐ No
☐ Unsure
Do you require housing subsidy?
☐ Yes
☐ No
☐ Unsure
Do you have family involvement?
☐ Yes
☐ No
☐ Unsure
Do you have caregiver involvement? ☐ Yes
☐ No
☐ Unsure
Do you have a community support network? ☐ Yes ☐ No ☐ Unsure
Which program would you like to use to transition to the community?
☐ CCT-CTS
☐ CTS-EBD
CCT Options Counseling Referral Information Form – December 2017
Page 1 of 2
Options Counseling Referral Information Form
Date Referral Received:
ADRC Region/ILC Responding to Referral:
Referral Type: ☐ Self
☐ MDS Section Q
☐ Family/Friend
☐ Ombudsman/Advocate
☐ Other:
Nursing Facility:
Contact Name:
Phone:
Email:
Resident Information
Name:
Nickname:
Date of Birth:
Guardian Name
:
(if applicable)
Guardian Phone:
Check all that apply: ☐ Elderly
☐ Behavioral Health
☐ Physical Disability
☐ Intellectual Disability
Health First Colorado Eligible: ☐ Yes ☐ No ☐ Pending
Health First Colorado ID#:
If Health First Colorado eligible, Long-Term Care eligible: ☐ Yes
☐ No
☐ Unsure
Nursing Facility admission date:
Rehab stay: ☐ Yes
☐ No
☐ Unsure
Physician Name:
Phone:
Desired Housing Type: ☐ Apartment ☐ House
☐ Group Home ☐ Host Home
☐ Assisted Living Facility
Desired Transition Location:
Do you have a home to return to?
☐ Yes
☐ No
Is accessible housing required? ☐ Yes ☐ No
Do you require affordable housing? ☐ Yes
☐ No
☐ Unsure
Do you require housing subsidy?
☐ Yes
☐ No
☐ Unsure
Do you have family involvement?
☐ Yes
☐ No
☐ Unsure
Do you have caregiver involvement? ☐ Yes
☐ No
☐ Unsure
Do you have a community support network? ☐ Yes ☐ No ☐ Unsure
Which program would you like to use to transition to the community?
☐ CCT-CTS
☐ CTS-EBD
CCT Options Counseling Referral Information Form – December 2017
Page 1 of 2
Resident Statement
☐ I will explore options to make the transition to living in the community.
☐ I have decided not to explore options to make the transition to living in the community at this time.
(Resident Initials) I have received information regarding Transition Coordination Agencies
and Case Management Agencies that provide community transition services. I have chosen the following
agencies:
Resident Provider Preferences
Transition Coordination Agency:
Contact Name:
Phone:
Case Management Agency (for ICM services):
Contact Name:
Phone:
Resident Signature:
Printed Name:
Date:
☐ Resident
☐ Legal Guardian
☐ Legal Representative
Options Counselors – Complete and submit a copy of this form to the selected transition coordination
agency, case management agency and the Department
Teresa.Nguyen@state.co.us
Retain a copy for your records.
CCT Options Counseling Referral Information Form – December 2017
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