"Inventory Checklist for Habilitation Center Moves" - Missouri

Inventory Checklist for Habilitation Center Moves is a legal document that was released by the Missouri Department of Mental Health - a government authority operating within Missouri.

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INVENTORY CHECKLIST
DUE DATE:
Individual’s Name:
DMH#:
No.
Entrance
No.
Exit
Items
(New Provider)
(Sending Provider)
Household Items
Bed
Dresser
Mirror
Night Stand
Lamp(s)
Mattress
TV
Radio
Stereo
DVD
CD Player
Video Game(s)
Couch
Chair(s)
End/coffee tables
Dining Room Set
VCR
Dishes
Flatware
Pots and Pans
Toaster
Skillets
Microwave oven
Hangers
Bed/Bath Linens
Comforter(s)
Sheets
Pillow(s)
Pillow case(s)
Bath towel(s)
Personal Care Products (ISL only)
Mouthwash
Deodorant
Toothpaste
Toothbrush
Comb
Brush
Soap
Razor
Inventory Checklist for Habilitation Center Moves
Page 1 of 3
INVENTORY CHECKLIST
DUE DATE:
Individual’s Name:
DMH#:
No.
Entrance
No.
Exit
Items
(New Provider)
(Sending Provider)
Household Items
Bed
Dresser
Mirror
Night Stand
Lamp(s)
Mattress
TV
Radio
Stereo
DVD
CD Player
Video Game(s)
Couch
Chair(s)
End/coffee tables
Dining Room Set
VCR
Dishes
Flatware
Pots and Pans
Toaster
Skillets
Microwave oven
Hangers
Bed/Bath Linens
Comforter(s)
Sheets
Pillow(s)
Pillow case(s)
Bath towel(s)
Personal Care Products (ISL only)
Mouthwash
Deodorant
Toothpaste
Toothbrush
Comb
Brush
Soap
Razor
Inventory Checklist for Habilitation Center Moves
Page 1 of 3
Items
No.
Entrance
No.
Exit
(New Provider)
(Sending Provider)
Clothing
Undergarments
Shirts
Pants
Shoes
Socks
Jacket
Gloves
Boots
Skirts/Dresses
Sweaters
Medication
Doctor’s orders for medications within last 30
days.
Supply of medications in acceptable script, 30
days preferred.
(List all w/dosage)
Adaptive Equipment
Clinical Folder
(Please attach to Checklist and Return to Service Coordinator)
Dental examination w/in last 12 months.
Medicaid Card.
Social Security Card, if available.
Hepatitis Series report and Immunization
record. If not available, then statement that
it’s not available signed by Support
Coordinator.
Pertinent medical information that may
include: Tuberculin skin test and results or
chest x-ray, screening for contagious diseases,
CBC report, urinalysis (UA), consultation
reports as appropriate, GYN, ophthalmology,
ENT, neurologist, etc.
Inventory Checklist for Habilitation Center Moves
Page 2 of 3
Items
No.
Entrance
No.
Exit
(New Provider)
(Sending Provider)
Annual physical examination within last 12
months or provider should make appointment
to get physical as soon as possible.
Psychological evaluation, if one has been
done.
Personal Plan, Personal Plan Reviews,
Behavior Support Plan.
Current Monthly Review-last 3 months.
Emergency Information form.
Guardianship papers.
Functional Assessment.
Spending Money/Start-up
Miscellaneous Items
Sending Provider Staff
By signing this Inventory List, you are stating that the above items checked, have been discharged
to the provider agency, accompanying the consumer to his/her new home.
Provider Staff Signature
Date
Receiving Provider Staff
By signing this Inventory List, you are confirming receipt of the above items checked, which have
accompanied the consumer to his/her new home.
Provider Staff Signature
Date
NOTE: Copies shall be given to Sending Provider Agency and the Regional Office.
Inventory Checklist for Habilitation Center Moves
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