ICAP INFORMATION
Check/Mark Type of ICAP:	PRIORITY	INITIAL
Date Submitted by Community Navigator (CN) or DDDS Support Coordinator (SC):	Date:	C.
If the individual requesting evaluation is living at home, is he/she presently attending a day program?
YES	NO	N/A
* If the individual is living at home and not receiving a day service, and day or residential services are not planned in the near future, an ICAP should not be requested. *
Date:	.	DOB:	.	MCI #:	.
Individual Name:	.	SS#:	.
Address:	.	County:	.
City:	.	State:	Zip Code:	.
Individual Phone:	.	Alternate Phone:	.
Residence: * Don’t Leave Blank
Residential Service Provider (if applicable):
Individual’s Graduation Date (If they are in School):	Cl
Reason for the Referral:
Other:	.
Daytime Activity: * Don’t Leave Blank	Other:	.
Employer’s Name (if applicable):	.
Day Service Provider Name (if applicable):
School Name (if applicable):
Teacher/Para Name:	.	E-Mail:	.
Teacher/Para Phone:	.	School Phone:	.
Parent, Guardian, Supported Decision Maker:	.
Home Phone:	.	Mobile Phone:	.
Parent, Guardian, Supported Decision Maker E-Mail:	.

CN or DDDS SC:	.	E-Mail:	.
CN or DDDS SC Contact Info:
Office Phone:	.	Mobile Phone:	.
CN or DDDS SC Supervisor:	.	E-Mail:	.
CN or DDDS SC Supervisor Contact Info:
Office Phone:	.	Mobile Phone:	.
DIAGNOSIS - Please check off all documented diagnosis for the individual:
Autism Spectrum Disorder (F84.0)	Unspecified Intellectual Disabilities (F79)
Prader-Willi Syndrome (Q87.1)	Cerebral Palsy Unspecified (G80.9)
Down Syndrome Unspecified (Q90.9)	Traumatic Brain Injury unspecified (S06.9)
Other - Specify ICD 10 Code:	.	Other - Specify ICD 10 Code:	.
Other - Specify ICD 10 Code:	.	Other - Specify ICD 10 Code:	.
MEDICATION LIST - Name of current medication and why medication is needed:
Medication Name	Purpose of Medication: (Ex: Seizures, Anxiety, Diabetes)	Formal Diagnosis
.	.	Yes No
.	.	Yes No
.	.	Yes No
.	.	Yes No
.	.	Yes No
RESPONDENTS:
List 3 people who have regular contact with the service recipient (at least 3xs per week) and are familiar with the service recipient’s direct support needs. Examples: Family Caregiver, Direct Support Professional, Job Coach, Teacher, Paraprofessional, etc.
Please include at least one respondent from the service recipient’s home/residential setting and school/day setting.
CN/SC needs to contact each of the respondents BEFORE sending the referral for the ICAP to the TCM/SC Supervisor; we want to make sure the respondents know why the SBA will be contacting them.
Name	Relationship	Cell #	Home #	Email Address	Contacted regarding interview process.
.	.	.	.	.	Yes No
.	.	.	.	.	Yes No
.	.	.	.	.	Yes No
If three respondents are not provided, please detail the reason for not listing three
respondents:	.
Please check off that the following are attached to this request:
Most recent Psychological Evaluation
Most recent Annual Physical
Most recent Psychiatric Evaluation for those receiving Psychiatric Services
Most recent Nursing Assessment/Nursing Intake
HELPFUL NOTES FOR INTERVIEWER TO KNOW REGARDING INDIVIDUAL REQUESTING EVALUATION:
.
Please make sure you list Cell phone, Home phone, and Email address, if available, for each Respondent you list on ICAP Information List. This will limit the amount of time it takes to get ICAP’s completed in a timely manner. If information is inaccurate or not current on the Information List, the ICAP will be returned to the State as INCOMPLETE and will have to be resubmitted by CN/DDDS SC with correct information.