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Effective Date: 



Updated 2/2018


Form 1058 is used by a Local Intellectual and Developmental Disability Authority (LIDDA) to request a Home and Community-based Services (HCS) crisis diversion slot.


Before submitting a request, an LIDDA is responsible for determining that an individual meets all of the criteria and qualifications for an HCS crisis diversion slot in accordance with HHS protocol.

When to Prepare

Following an LIDDA’s determination that an individual meets all of the criteria and qualifications for an HCS crisis diversion slot, the LIDDA completes the form and submits it to HHS along with all required supporting documentation.

Detailed Instructions

LIDDA Information

Date of Request — Enter the date the LIDDA staff completed the form.

LIDDA Name — Enter the name of the LIDDA.

Comp Code  — Enter the component code of the LIDDA.

LIDDA Contact Person — Enter the name of the LIDDA staff who is designated as the LIDDA contact.

Email Address — Enter the email address for the LIDDA contact.

Phone Number — Enter the area code and phone number for the LIDDA contact.

Individual Information

Individual Name — Enter the individual’s full name as it appears in the Client Assignment and Registration (CARE) System.

CARE ID — Enter the CARE ID number for the individual.

Date of Birth — Enter the individual’s date of birth.

Age — Enter the individual’s age.

Full Scale IQ — Enter the individual’s full scale IQ number.

Name of Legally Authorized Representative (LAR), if any — Enter the full name of the individual’s LAR.

Address of LAR — Enter the LAR’s address.

Where is the individual currently residing? — Check the appropriate box. If the individual is living at home, check the “Home” box and indicate whether the individual lives in his/her family’s home or in his/her own home. If the individual is living in a facility, check the “Facility” box and enter the type of facility and the name of the facility’s operator. Examples: ICF/IID operated by Wind River or Crisis Respite Home operated by the Harris Center.

Name of advocate and advocate’s organization assisting the individual/LAR with request, if any — If the individual/LAR is receiving assistance with this request from an advocate, enter the name of the advocate and the name of the advocate’s organization.

Individual’s diagnoses — List all diagnoses assigned to the individual beginning with intellectual disability and developmental disabilities diagnoses.

Current medications and medical/assistive devices — List all current medications and medical/assistive devices used by the individual.

Community Resources

Has out-of-home placement been requested? — Check Yes or No, as appropriate.

Has an ICF/IID search been completed? — Check Yes or No, as appropriate.

Results of ICF/IID Search — For each facility searched, enter the facility name, date of referral, and the facility’s response.

Psychiatric and behavioral treatment admission in the past five years — For each admission in the past five years, enter the facility name, date of admission, reason for admission, and discharge date.

List all service attempts and provide explanation why the service was not adequate in supporting the individual — Self-explanatory. (Types of services include general revenue-funded services, Community First Choice services, crisis intervention services, STAR+PLUS managed care, Medicaid waiver program, local school district services.)

What services are needed for the individual to live in a community setting? – Describe the services and supports the individual needs to living in a community setting.

Case Summary — In narrative form, provide a detailed summary of the individual’s case and why the LIDDA believes he/she is at imminent risk of admission to an institution without services and supports through the HCS program.

Form Submission

The LIDDA scans the completed form and all supporting documentation and sends by secure email to