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Customer’s Name: ............................................................................................................

PART A was completed by:  Customer  SSR  Telephone Contact  Other ............................................................

PART B (to be competed by SSR)

1. Is current medical report from customer’s treating facility/doctor? If no, explain why not: .................................................................

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2. From your contact with and observation of the customer, describe any physical, mental, and/or social factors you feel might impair the customer’s ability to support self.

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3. CUSTOMER’S STATUS WITH REHABILITATION/TREATING FACILITIES (List if active at time of application and/or actions taken on team recommendations at time of review.)

Date NOT ACCEPTED OR Name of Agency/Facility Referred ACTIVE CASE CLOSED

............................................................. ....................................  

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Has customer refused or failed to follow through with training or treatment? ...................... If yes, explain: ..........................................

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4. REMARKS:

SSR: ................................................................................................................ Date: ....................................................