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Home
About US
Resources
Services
CIL's in TN
Calendar
Donate
Contact Us
T.A.R.P. Center for Independent Living
Intake Form, CNA, and Goals
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Indicates required field
I am filling out this form for someone else
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Yes
No
Name of Person filling out form
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First
Last
Name of Person needing services
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First
Last
Date
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Email
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Address
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Line 1
Line 2
City
State
Zip Code
Country
County of Residence
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Home Phone Number
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Cell Phone Number
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Date of Birth
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Gender
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Race
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Ethnic Origin
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Hispanic/Latino
Non Hispanic
Head of Household
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Yes
No
Number in Household
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Number of children
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Marital Status
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Veteran?
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Yes
No
Do you have a legal guardian or power of attorney (POA)?
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Yes
No
Guardian or POA Name:
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First
Last
Guardian or POA Address
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Line 1
Line 2
City
State
Zip Code
Country
Guardian or POA Best Phone Number
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Guardian or POA Email
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Emergency Contact Name
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First
Last
Emergency Contact Phone Number
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Do you need any of the following accommodations?
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Braille Print
Digital Format
Large Print
Interpreter Services
None
Disability Service Connected?
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Yes
No
Date of Service
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Previous Rehabilitation Services (PT, Voc Rehab, etc…):
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Other Agencies Currently Involved
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Home Health
LIHEAP
SNAP
Mental Health Services
State Program for Blind/Visually Impaired
State Program for Deaf/Hard of Hearing
None
Other
Do you have a significant disability?
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Yes
No
I have the following significant disability(ies):
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Self-Identifies
Mental/Emotional
Physical
Hearing
Vision
Multiple Disabilities
Cognitive
Other
None
Primary Disability
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Secondary Disability
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Additional Comments?
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My disability(ies) substantially limit me from functioning independently in the following area (s):
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Self-Care
Mobility
Education
Employment
Housing
Other (Specify Below)
Other
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Housing
Living Situation? (Rent, Own, Live with Family/Friend, Homeless)
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Accessible?
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Yes
No
Are you in the process of transitioning from a facility?
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Yes
No
Relocated from Institution (date if applicable)
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Prevented Relocation (date if applicable)
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Transportation
Do you have reliable transportation?
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Yes
No
Notes
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Communication
Do you have difficulty in understanding others or understanding verbal instructions?
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Yes
No
Are you confident in making your own decisions?
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Yes
No
Notes
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Self-Care
Do you need assistance with dressing?
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Yes
No
Do you need assistance with toileting?
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Yes
No
Do you need assistance with eating?
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Yes
No
Do you need assistance with grooming/personal hygiene?
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Yes
No
Notes
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Independent Living Daily Activities
(Does not apply for young children/school age children)
Do you need someone to fix/cook your meals?
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Yes
No
N/A
Do you need assistance with shopping?
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Yes
No
N/A
Do you need assistance with household chores?
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Yes
No
N/A
Do you need help with managing your money?
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Yes
No
N/A
Notes
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Equipment
Do you use any other kind of special equipment throughout the day? (wheelchair, rollator, walker, ect)
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Yes
No
Do you use any specialized equipment in the bathroom? (Shower grab bars, toilet bars, seat riser, shower chair)
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Yes
No
Do you require the use of incontinence wear?
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Yes
No
Notes
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Food Security
Do you have enough food in your home?
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Yes
No
Do you need assistance getting SNAP benefits or commodities?
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Yes
No
Are you unable to get food and supplies due to lack of mobility or transportation?
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Yes
No
Notes
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Self-Direction
Do you have to be reminded to dress, eat, bathe….?
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Yes
No
Do you need someone to coordinate your personal care?
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Yes
No
Are you aware of dangers around you?
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Yes
No
Notes
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Employment
Do you have gainful employment?
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Yes
No
Do you want gainful employment?
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Yes
No
Health Insurance
Do you currently have health insurance?
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Yes
No
Do you have prescription coverage?
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Yes
No
Do you have Medicare?
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Yes
No
Do you have Medicaid?
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Yes
No
Do you have private/commercial insurance?
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Yes
No
Notes
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House Modifications for Access
Do you currently use a wheelchair or suffer from a neurological or physical disability that prevents you from accessing your home?
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Yes
No
Do you need a bathroom modification? (Referrals will be given)
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Yes
No
Do you need a ramp for home access? (Referrals will be given)
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Yes
No
Do you need other home modifications for accessibility? (Referrals will be given)
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Yes
No
Notes
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Voting
Are you a registered voter?
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Yes
No
Would you like help registering to vote?
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Yes
No
Independent Living Plan and Goals
What do you need and how will it help?
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Covid-19 Related?
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Yes
No
The services I am requesting will help me: (Please check all that apply)
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Improve my ability to function in my family or community.
Maintain my ability to function in my family or community.
Obtain, maintain or advance in employment.
I was directly involved in the development of this Independent Living Plan and agree to
participate in these services. I understand that I am not legally bound as a contract but I
affirm that I am committed to work toward achieving these goals and hope to achieve the
first goal by:
Goal Date
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Approval or Waiver of Independent Living Plan
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I accept the Independent Living Plan outlined above. I will work alone or with my ILS toward my goals.
I waive the right to establish an Independent Living Plan. I choose to develop my goals on my own and will seek advocacy when I feel it is needed.
Any request for services or equipment is subject to approval and availability.
Upon approval you will be notified.
Permission to Release/Receive Information
I give T.A.R.P. CIL permission to contact
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For the purpose of
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Releasing Information
Receiving Information
Information allowed to be shared
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The only information released or received will be regarding the Independent Living Services the consumer has requested.
The release of this information is in effect until expiration date 1 year after date signed.
I understand that this information will Be kept confidential. It Will not be discussed or released to anyone, other than who is listed on the release.
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Yes
Grievance & Conciliation Procedure
If a consumer meets any action, occurrence or attitude, either expressed or implied, by
a staff, that the consumer perceives as unfair or inequitable, he/she is expected to
discuss it with the staff person involved.
If that does not resolve the issue, the consumer may appeal in writing to the Executive
Director, T.A.R.P. Center for Independent Living (T.A.R.P. CIL), 1027 Mineral Wells
Ave. Suite 7, Paris, TN 38242. The Executive Director will meet with the consumer and
respond to the appeal within seven (7) business days.
If not satisfied, you may appeal in writing within (5) business days to the Board of
Directors, T.A.R.P. Inc, 1027 Mineral Wells Ave. Suite 7, Paris, TN 38242. A hearing
will be held, and the Board of Directors will respond to you within (10) business days.
Consumers may engage, at their own expense, a lawyer or other agent to represent
them during the appeals process. Contacts to aid consumers are available in the state
of Tennessee through: Disability Rights TN 1-800-342-1660 (TTY) 1-888-852-2852
www.disabilityrightstn.org gethelp@disabilityrightstn.org
Client Rights
T.A.R.P.’s number one goal is to partner with you to help maintain or increase your
independence. In the event of being dissatisfied with any decisions concerning the delivery or
denial of services, you have the right to appeal the decisions of the IL Specialist in accordance
with T.A.R.P.’s policy for Grievance for Consumer and Community Members. Furthermore, you
have the right to discuss any questions or problems with the
Client Assistance Program (CAP).
Disability Rights TN 1-800-342-1660 (TTY) 1-888-852-2852
www.disabilityrightstn.org gethelp@disabilityrightstn.org
TARP provides equal services to all persons without regard to race, color, religion, disability, sex, age, or national origin
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I have read and received the above information on CAP
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Yes
I give permission for TARP Center for Independent Living Grantors to view my files, if necessary.
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Yes
I certify all information is true and correct to the best of my knowledge.
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Yes
By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this form.
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I Accept
ILS Signature (In Office Use Only)
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Date (In Office Use Only)
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Submit
