DSS-3602B rev. 01/08/2008 (Page 11 of 14)
Human Resources Administration Medical Insurance and Community Services Administration Adult Protective Services
19. RELATIVES AND OTHER INFORMAL SUPPORTS. List known family members, friends and other persons who have been contacted. Describe what assistance, if any, can be provided by each person that is identified. Name Relationship to the adult Telephone What assistance can be provided?
20. OTHER SERVICES. List all other services that are currently in place. Provider Agency Contact Person Telephone
Service Provided. (Specify frequency/hours)
COMMENTS:
21. INCAPACITATING ILLNESSES OR INJURIES. Indicate all known or suspected conditions. c Mental illness d e f g g Physical disability, frailty c d e f c Mental retardation d e f g c Alcoholism d e f g c Alzheimer's disease or other aging related dementia d e f g c Acute illness or injury (specify) d e f g
c d e f g
Drug or other substance abuse
c d e f g
Other (specify)
22. ABILITY AND WILLINGNESS OF OTHERS TO ASSIST RESPONSIBLY: Do the adult's needs exceed the ability and willingness of family members, friends and other c Yes g d e f g c No d e f service providers to provide services to the client? If the client has someone who is willing and able to assist with the risks he/she is facing, he/she is not eligible for APS. 23. ADDITIONAL COMMENTS: