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Effective Date: 
6/2010

Documents

 

Instructions

Updated: 4/2012

 

Purpose

To ensure current contact information for the parent or LAR of an individual under 22 years of age who is receiving supervised living or residential support in the Home and Community-based Services (HCS) Program, should the service coordinator (SC) or HCS provider need to get in contact with the parent or LAR.

 

Procedure

When to Prepare

When the SC or HCS provider first meets with the parent or LAR, the SC or HCS provider requests that the parent or LAR provide the information requested on Form 3605/3605-S. The SC or HCS provider explains to the parent or LAR that the information will be used to contact the parent or LAR in the event of an emergency situation or to invite the parent or LAR to a planning meeting. The SC or HCS provider asks the parent or LAR to update the information on an annual basis.

Form Retention

The HCS provider retains the original or a copy of Form 3605/3605-S in the individual's record until the individual turns 22 years of age.

 

Detailed Instructions

Name of Individual Receiving HCS Services — Enter the name of the individual receiving HCS services.

Name of Parent/LAR — Check the appropriate box and enter the person’s name.

Telephone No(s). of Parent/LAR (Home and Cell) — Enter the telephone number(s), with area code, for the person named as parent or LAR.

Driver License No. of Parent/LAR — Enter the driver license number for the person named as parent or LAR.

State of Issuance — Enter the name of the state that the driver license was issued.

Department of Public Safety (DPS) Identification Card No. — If the parent/LAR does not have a driver license, enter the identification card number issued by DPS.

Employer of Parent/LAR — If the parent/LAR is employed, enter the name of the employer.

Employer Telephone No. — Enter the telephone number, with area code, of the employer.

Employer Address — Enter the address of the parent/LAR's employer.

Emergency Contact Information

Name of Relative/Other Person the HCS Provider, Service Coordinator or HHSC May Contact — Enter the name of the emergency contact person.

Telephone No(s). (Home and Cell) — Enter the telephone number(s), with area code, of the emergency contact person.

Address — Enter the address of the emergency contact person.

Driver License No. and State of Issuance (optional) — If the parent/LAR provides the information, enter the emergency contact person’s driver license number and state of issuance. Inform the parent/LAR that providing the information is optional.

DPS Personal Identification Card No. (optional) — If the parent/LAR provides the information, enter the emergency contact person’s identification card number issued by DPS. Inform the parent/LAR that providing the information is optional.

Employer (optional) — If the parent/LAR provides the information, enter the emergency contact person’s place of employment. Inform the parent/LAR that providing the information is optional.

Employer Telephone No. (optional) — If the parent/LAR provides the information, enter the emergency contact person's employer's telephone number, with area code. Inform the parent/LAR that providing the information is optional.

Employer Address (optional) — If the parent/LAR provides the information, enter the employer address fo the emergency contact person. Inform the parent/LAR that providing the information is optional.

Name of Service Coordinator — Enter the name of the service coordinator.

Name of HCS Program Provider Representative — Enter the name of the HCS provider representative.

Attestation — Enter the name of the parent/LAR in the first space and the name of the individual under 22 years of age in the second and third spaces.

Ask the parent/LAR to notify the SC and HCS provider of any changes to the contact information provided and to make reasonable efforts to participate in the individual’s life and in planning activities for the individual.

Inform the parent/LAR that if the contact information on Form 3605/3605-S is not provided or is not accurate and the SC and HHSC are unable to locate the parent/LAR, then HHSC will refer the case to the Department of Family and Protective Services.

Printed Name-Parent/LAR — Enter the printed name of the parent/LAR.

Signature-Parent/LAR — The parent/LAR signs the form.

Date — Enter the date the parent/LAR signs the form.