DSS-3602B rev. 01/08/2008 (Page 12 of 14)
Human Resources Administration Medical Insurance and Community Services Administration Adult Protective Services
, 24. IS THE ADULT ELIGIBLE FOR APS?
c Yes d e f g
c No d e f g
Mental or Physical Impairment
c Yes d e f g
c No d e f g
Actual or Threatened Harm
c Yes d e f g
c No d e f g
No One Willing and Able to Assist Responsibly
c Yes d e f g The client must meet all three eligibility criteria to receive APS.
c No d e f g
c The adult retains decision making capacity and is refusing all offers of assistance. Case will not d e f g be accepted for APS. Explain what efforts have been made to engage the adult.
Client Assessment Completed and Reviewed Print Name
Signature
Date
Caseworker Supervisor
IF THE CLIENT IS NOT ELIGIBLE FOR APS, STOP HERE AND COMPLETE THE DSS-3602C. IF THE CLIENT IS ELIGIBLE FOR APS, CONTINUE COMPLETING THE SERVICE PLAN COMPONENTS OF THIS DOCUMENT FOR RISK AREAS IDENTIFIED. 25. CLIENT CONCURRENCE/RIGHT TO SELF DETERMINATION. Check the one box that applies most accurately and respond to appropriate questions. c The adult participated fully in the service plan and agreed to accept services. d e f g c The adult was unable to participate in the service plan because of mental limitations, but agrees to accept services. d e f g c The adult is refusing services, but additional efforts will be made to persuade the adult to accept services d e f g voluntarily. c The adult is refusing to accept services and involuntary intervention is necessary. Indicate what risks will be d e f g addressed by involuntary services and why additional voluntary efforts are not possible.
26. OBJECTIVE. Choose the objective which best describes the current goal of services. Long term placement is a placement of 6 months or more. c Adult to be maintained in the community with voluntary services. d e f g c Adult to be maintained in the community, some involuntary services will be necessary. d e f g c Long term placement in a residential care facility is needed, the adult concurs to placement, or efforts will be d e f g made to convince the adult to accept placement. c Involuntary legal intervention will be pursued for the purpose of authorizing long term placement in a residential d e f g care facility. c Other (describe) d e f g