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Effective Date: 
10/2019

Documents

 

Instructions

Updated: 10/2019

 

Purpose

Form 1051 is used when the Department of Family and Protective Services (DFPS) staff request a local intellectual developmental disability authority (LIDDA) conduct a determination of intellectual disability (DID) for a person placed into Child Protective Services managing conservatorship or when a person is referred for guardianship with the Texas Health and Human Services Commission (HHSC).

 

When to Prepare

DFPS will submit the request no later than the person’s 16th birthday. If the person is placed in the managing conservatorship of DFPS after the person’s 16th birthday, the request will be made no later than 90 days after the person’s initial assessment. The LIDDA is responsible for conducting the DID and completing the DID report as soon as possible, but no later than six months after receiving the request.

 

Detailed Instructions

Section 1 Completed by the Texas Department of Family and Protective Services (DFPS) staff. After completing Section I, DFPS staff submits a copy of the form via secure email or fax to the contacts for the LIDDA. At the same time, DFPS notifies the HHSC IDD Services Local Procedure and Development and Support (LPDS) Unit of the DID request by submitting a copy of the form by encrypted email to LIDDARequests@hhsc.state.tx.us. The subject line should read "Form 1051."

Note: If a secure email is not available, request a secure email from the HHSC reviewer to submit a copy of the form securely.

 

Department of Family and Protective Services (DFPS) Contact Information

DFPS Contact Name – The DFPS contact enters his/her name.

DFPS Contact Email – The DFPS contact enters his/her email.

DFPS Contact Telephone No. and Area Code – DFPS staff enters his/her area code and phone number.

DFPS Contact Fax No. and Area Code – DFPS staff enters his/her area code and fax number.

Date of DID Request – DFPS staff enters the date the DID is being requested.

Reason for DID Request (check one) – DFPS staff checks one of the boxes to indicate the reason for requesting the DID.

 

Person’s Information

Name of Person – DFPS staff enters the person’s first and last name.

Person’s Medicaid No. – DFPS staff enters the person’s Medicaid Number.

Person’s Social Security No. – DFPS staff enters the person’s Social Security number.

Date of Birth – DFPS staff enters the person’s date of birth.

Age in Years and Months – DFPS staff enters the person’s age, including the months.

Address of Current Placement – DFPS staff enters address of person’s current placement.

Placement County – DFPS staff enters county of person’s current placement.

 

LIDDA Information Where the Person Resides

LIDDA Name – DFPS staff enters the LIDDA for the county in which the person resides. To identify which LIDDA serves the area where the individual resides, search the following link: https://hhs.texas.gov/about-hhs/find-us/where-can-i-find-services.

LIDDA Contact Name – DFPS staff enters the LIDDA contact person’s name. To identify the LIDDA contact, use information provided by LPDS.

LIDDA Contact Telephone No. and Area Code – DFPS staff enters the area code and phone number for the LIDDA contact. To identify the LIDDA contact, use information provided by LPDS.

LIDDA Contact Fax No. and Area Code – DFPS staff enters the area code and fax number for the LIDDA contact. To identify the LIDDA contact, use information provided by LPDS.

LIDDA Contact Email – DFPS staff enters the email for the LIDDA contact. To identify the LIDDA contact, use information provided by LPDS.

 

Section 2 – Completed by the LIDDA if the person moved to a different LIDDA catchment area upon receiving the DID request from DFPS. The LIDDA notifies the receiving LIDDA and submits a copy of the form to the receiving LIDDA via secure fax or email. The LIDDA scans the completed form and sends by encrypted email to HHSC LPDS at LIDDARequests@hhsc.state.tx.us. The subject line should read "Form 1051."

Note: If a secure email is not available, request a secure email from the HHSC reviewer to submit a copy of the form securely.

 

Reassigned LIDDA Information (Due to Person’s Change of Address and Placement County)

Address of Current Placement – LIDDA staff enters the address of the person’s current placement.

Placement County – LIDDA staff enters the county of the person’s current placement.

Receiving LIDDA Name – LIDDA staff enters the name of the LIDDA in the area which person currently resides.

Receiving LIDDA Contact Name – LIDDA staff enters the appropriate receiving LIDDA contact name.

Receiving LIDDA Contact Telephone No. and Area Code – LIDDA staff enters the area code and phone number for the receiving LIDDA section contact.

Receiving LIDDA Area Code and Fax No. – LIDDA staff enters the area code and fax number for the receiving LIDDA section contact.

Receiving LIDDA Contact Email – LIDDA staff enters the email for the receiving LIDDA section contact.

Date Sent to Receiving LIDDA – LIDDA staff enters the date the form was sent to the receiving LIDDA contact.

Date Notified DFPS – LIDDA staff enters the date the LIDDA notified DPFS of the LIDDA reassignment.

Date Notified Local Procedure Development and Support (LPDS) – LIDDA staff enters the date the LIDDA notified LPDS of the LIDDA reassignment.

 

Section 3 – Completed by the LIDDA after conducting the DID. The LIDDA conducts the DID and provides a copy of the completed form and DID report to the DFPS contact no later than six months after receiving the request. The written report must be provided within 30 days after completing the interview and DID assessment. The LIDDA scans the completed form and sends by encrypted email to HHSC LPDS at LIDDARequests@hhsc.state.tx.us. The subject line should read "Form 1051."

Note: If a secure email is not available, request a secure email from the HHSC reviewer to submit a copy of the form securely.

Name of LIDDA Staff Completing Form – LIDDA staff completing the form enters their name.

LIDDA Staff Area Code an Telephone No. – LIDDA staff enters their area code and phone number.

Date DID Request Received – LIDDA staff enters the date in which they received the DID Request.

Date DID Completed – LIDDA staff enters the date in which the DID was completed.

Date of DID Results Sent to DFPS – LIDDA staff enters the date in which they sent the DID Results to DFPS.

Person’s Client Assignment and Registration (CARE) System ID – LIDDA staff enters the person’s CARE identification number.