DDRC - Unmet Needs Application

Contact Information

Name of Individual Funding is For:

Email Address:

DOB:

Form Completed By:

Age:

Relationship to Individual:

Confirmed Delay/Diagnosis:

Yes

Please submit proof of Delay Determination or IDD/DD Diagnosis*

Add Attachment:

Waiver Information

Please check which HCBS waiver the applicant is enrolled in if they are not enrolled in an IDD/DD waiver mark N/A:

CES

SLS

DD

EBD

CHCBS

CLLI

BI

N/A

Paramater 1: Disability/Overall Care Needs:

Mobility Needs:

Person can walk independently; mobility is not limited person has full use of hands and feet.

Person can walk with some assistance has use of hands and feet.

Limited use of hands and feet; person is unable to walk; person can partially assist with transfers; weight/size is not a problem.

Person is unable to walk or move around alone; unable to assist with transfers and/or their weight/size makes transfers difficult.

Medical/Nursing Care Needs:

Person does not require any more medical care than routine medical appointments.

Person requires more medical care than routine medical visits.

Person requires medical care for a frequent and acute illness or medical condition.

Person has medical needs that significantly impact their ability to participate in home, school, and community activities.

Transportation Needs:

Person/family has a typical transportation situation.

Person/family’s participation in home, school, or community activities is interrupted by access to transportation at least once a week.

Person/family’s participation in home, school, or community activities is interrupted by access to transportation more than once a week.

Person/family has no reliable access to transportation.

Supervision Needs:

Supervision typical for that age.

Person needs occasional supervision.

Person requires frequent supervision.

Person requires constant supervision (can never be unsupervised).

Perimiter 2: Behavior:

Impact of the Behavior

There are no behavioral concerns.

There are mild behavioral concerns. May require verbal reminders, redirection, or supervision but usually do not result in injury to self, others, or property.

There are moderate behavioral concerns. Exhibits inappropriate behaviors that put self or others at risk; requires frequent interventions at least weekly.

There are extreme behavioral concerns. Exhibits inappropriate behaviors that put self or others at risk; requires frequent interventions at least daily.

Communication Needs:

There are no communication concerns.

There are mild communication concerns. Can consistently meet needs & wants through limited verbal skills with familiar and unfamiliar people.

There are moderate communication concerns. Uses alternative means to communicate such as pointing, PECS, or device; understood only by familiar people.

There are extreme communication concerns. Limited or inconsistent ways of communicating with others.

Paramater 3: Family Composition & Stability:

Please mark the box that best represents your family/living situation.

Relationships are strained within the family.

N/A

Mild

Moderate

High

There are other children or adults with disabilities/delays/illnesses in the home.

N/A

Mild

Moderate

High

Siblings show signs of stress due to a family member with an I/DD living in the home.

N/A

Mild

Moderate

High

Our family has responsibility for other extended family members.

N/A

Mild

Moderate

High

Within the last year there has been a divorce, separation, death, or addition to the family.

N/A

Mild

Moderate

High

Our family's activities center on the needs of the family member with an I/DD. Caregiver(s) spends excessive time coordinating various needs for family member with I/DD.

N/A

Mild

Moderate

High

Caregiver(s) spends excessive time away from job to meet the needs of family member with an I/DD. Caregiver(s) has had to quit their job or is unable to work due to the needs of the family member with an I/DD.

N/A

Mild

Moderate

High

There are additional difficulties due to the aging/health of caregiver(s).

N/A

Mild

Moderate

High

Caregiver(s) experiences additional difficulties due to family member with an I/DD being home all day (no school/respite).

N/A

Mild

Moderate

High

Additional Comments:

Funding Needs:

JeffCo Unmet Needs Funding is to provide short-term financial support when you are experiencing costs not covered under any other alternative funding sources (i.e Medicaid, FSSP, etc.). These costs are above normal daily living expenses. We ask that after a request is approved, you work towards identifying other resources available for any ongoing, long-term support needs.

Please describe your funding request. What will these funds be used for?

What other available resources have you utilized?

Have you applied for and/or accessed JeffCo Unmet Needs before?

Yes

Date of previously applied for funding

Amount of previously applied for funding

Reason for previously applied for funding

Funding Specifics:

What items or services are you requesting funds for? Please note specifics if you have a program or provider in mind.

1: Name of Service or Item Needed

Support/Item Cost

Please include details about duration, cost per hour, etc.

Grand Total

Funding Limits:

DDRC reserves the right to limit the number of requests and total amount of dollars received in a fiscal year (FY24-25). Individuals are limited to 3 requests total each FY and a total maximum amount received of $2500, regardless of the number of requests. Funds must be used within the FY received July 1st, 2024 – June 30th, 2025.

DDRC Funding Options:

Receipt reimbursement- family submits receipt, paid invoice, or approved service log for reimbursement of out-of-pocket costs for authorized services.
Advance- funds are advanced to family to purchase authorized services with documented proof of expense. Family must submit receipt(s) following purchase within 30 days of the expense.
Direct vendor payment- DDRC purchases the item directly or pays an invoice or bill from the vendor. If DDRC does not already have an established relationship with the vendor, we will need the vendor’s W-9 (Your DDRC Community Funding Coordinator can assist with this).

I verify that the information stated above is true to the best of my knowledge.

Date

Contact Information

Name

Address

County

Phone Number