Person's Name:
*
First Name
Last Name
Date of Birth:
*
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Month
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Day
Year
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TCM Name:
*
TCM Email:
*
example@example.com
Date of Request:
*
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Month
-
Day
Year
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Signed current Person Centered Support Plan (PCSP) demonstrating need. If the person requesting services does not currently have a PCSP one shall be completed within 30 days of approval for waiver access:
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Minimum requirements necessary before a request can be reviewed by the Crisis/Exception Review Comm.
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Signed current Behavior Support Plan (BSP) if applicable:
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Supported Employment requests: Persons transitioning from Vocational Rehabilitation Services (VRS) which require ongoing support to maintain employment and self-sufficiency, please upload the VRS closure letter indicating extended plan/ongoing support needs and job coaching notes.
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DCF/ANE documentation if applicable:
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Other pertinent documentation (if applicable) including, but not limited to: Physician recommendations, hospitalization reports, family member/neighbor statements, etc.:
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List Service(s) Being Requested.
Explain in Detail How Exception Funding Will Alleviate Current Situation:
Individual Signature
*
Do you have a guardian?
*
Please Select
Yes
No
Guardian Signature
Date
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Month
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Day
Year
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