The following are commonly used forms for the Division of Disability and Aging Services.

If you do not see a form you are looking for, please contact us at 802-241-2648.

A

• Agreement for Live-in Care (CFC 808)

• Appointing a Health Care Agent for People with Developmental Disabilities Cover Memo

• ARIS Employer Agreement

• ARIS Employer Handbook

• Assistive Devices & Home Modifications (CFC 807)

• Attendant Service Application

• Attendant Service Time Sheet

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B

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C

• Caregiver Registration Form, Vermont

• Case Management Action Plan Guidelines

• Choices for Care Program Application (CFC 801)

• Clinical Assessment (CFC 802)

• Clinical Certification (CFC 803)

• Clinical Certification and/or Highest Paid Provider Change (CFC 812)

• Clinical Eligibility Worksheet (CFC)

• Clinical Eligibility Worksheet - Reassessment (CFC)

• Commodity Supplement Food Program Application (CSFP)

• Children's Personal Care Services Application (CPCS)

• Children's Personal Care Services Assessment of Need (CPCS)

• Children's Personal Care Services Care Plan (CPCS)

• Critical Incident Report for Restraint (DDS)

• Critical Incident Report (DDS)

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D

• Day Health Rehabilitation Services Prior Authorization Form, Vermont

• Day Health Rehabilitation Services Prior Authorization Form Instructions, Vermont

• Developmental Services Application Form (DDS)

• Developmental Services Emergency Fact Sheet (DDS)

• Developmental Services Waiver Eligibility Form (DDS)

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E

• Emergency Contacts & Backup Plan (CFC 809)

• Employer Certification

• Enhanced Residential Care (ERC) Service Plan (CFC 805B)

• Enhanced Residential Care (ERC) Tier Worksheet for Comprehensive Resident Assessment (CRA)

• Enhanced Residential Care (ERC) Tier Worksheet for Resident Assessment (RA)

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F

• Flexible Choices Allowance (CFC 836)

• Flexible Choices Budget (CFC 835)

• Flexible Choices Consent (CFC 832)

• Flexible Choices Referral (CFC 831)

• Flexible Choices Self Screen (CFC 830)

• Flexible Choices Start of Services (CFC 833)

• Flexible Choices Stop of Services (CFC 834)

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G

• Guidelines for Completing the Mandatory Disclosure of Information to Home Providers and Respite Workers Form

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H

• Health Care Agent Disclosure Statement and Appointment of My Health Care Agent Form

• High Needs Wait List Score Sheet (CFC 810)

• High Needs Waiting List Monthly Follow-up Sheet (CFC 811)

• Highest Paid Provider Change (CFC 812)

• Home-Based & ERC Change Report (CFC 804)

• Home-Based Service Plan (CFC 805A)

• Home Provider Mandatory Disclosure Law Implementation Questions and Answers (DDS)

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I

• Independent Living Assessment (ILA) - Notification Memo

• Independent Living Assessment (ILA) - Revised Follow-up Memo

• Independent Living Assessment (ILA) - Full ILA

• Independent Living Assessment (ILA) - Health Section Only

• Independent Living Assessment (ILA) - Intake

• Independent Living Assessment Form (ILA) (TBI)

• Individual Service Plan Form (TBI)

• Individual Support Agreement Basic Form (DDS)

• Individual Support Agreement Required Approvals Form (DDS)

• Individual Support Agreement Review and Change Forms (DDS)
• Instructions for the 3-Year (FY '11 - FY -13) VT State System of Care Plan for Developmental Disability Services (DDS)

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J

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K

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L

• Life Skills Aide Report Form (TBI)

• Life Skills Aide Report Weekly Form (TBI)

• List of Interested Persons for a Guardianship (Probate Court Form No 75)
  If you are having difficulties accessing this form here is an alternative copy of the form Probate Court Form No 75

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M

• Mandatory Disclosure of Information to Home Providers and Respite Workers Form (DDS)

• Guidelines for Completing the Mandatory Disclosure of Information to Home Providers and Respite Workers Form
• Home Provider Mandatory Disclosure Law Implementation Questions and Answers (DDS)

• Model Guardianship Evaluation Form

• Moderate Group Wait List (CFC MOD 903)

• Moderate Needs Adult Day Services Wait List Notice(ADS)

• Moderate Needs Application & Request for Reinstatement (CFC MOD 900)

• Moderate Needs Clinical Worksheet (CFC MOD 901)

• Moderate Needs Complete Package Checklist (CFC MOD 907)

• Moderate Needs Group Annual Reassessment (CFC MOD 906A)

• Moderate Needs Group Change (CFC MOD 906B)

• Moderate Needs Group Financial Worksheet (CFC MOD 902)

• Moderate Needs Homemaker Services Wait List Notice(Homemaker Services)

• Moderate Needs Service Authorization (CFC MOD 904)

• Moderate Needs Termination (CFC MOD 905)

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N

• National Family Caregiver Support Program (NFCSP) Essential Forms
  Contact your local Area Agencies on Aging for all essential forms.

• Nursing Facility-Hospital-Discharge Notice (CFC 804A)

• Nursing Facility Changes (CFC 804B)

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O

• Omnia Electronic Assessment Forms (Omnia Interviewer Program)
  
  These forms are only for users of the Omnia Interviewer program.

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P

• Permission for Release of Information for LTCCCs (CFC)

• Permission for Release of Information for Providers (CFC)

• Personal Care Worksheet (CFC 806)

• Personal Care Worksheet Instructions (CFC)

• Petition for Guardianship Services for an Adult with Developmental Disabilities

• Petition to Appoint a Guardian for a Mentally Disabled Adult (Probate Court Form No 72)
  If you are having difficulties accessing this form here is an alternative copy of the form Probate Court Form No 72
  

• Probate Court Form No 72 - Petition to Appoint a Guardian for a Mentally Disabled Adult
  If you are having difficulties accessing this form here is an alternative copy of the form Probate Court Form No 72
  

• Probate Court Form No 73 - Statement of Proposed Ward's Assets & Income
  If you are having difficulties accessing this form here is an alternative copy of the form Probate Court Form No 73
  

• Probate Court Form No 75 - List of Interested Persons for a Guardianship
  If you are having difficulties accessing this form here is an alternative copy of the form Probate Court Form No 75

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Q

• Quarterly Report Form (TBI)

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R

• Resident Assessment

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S

• Senior Farm Share Applications - Abbreviated Application and Housing Site Contact Information

• Senior Farm Share Applications - Full Application Form (New Housing Sites)

• Senior Farm Share Program Contact Information (Housing Site Contact Information Form)

• Senior Farm Share Program Summary (Application Information)

• Senior Farmers' Market Nutrition Program (SFMNP) Application Cover Memo

• Statement of Proposed Ward's Assets & Income (Probate Court Form No 73)
  If you are having difficulties accessing this form here is an alternative copy of the form Probate Court Form No 73
  

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T

• Traumatic Brain Injury (TBI) Application Package Guidelines and Forms

• Traumatic Brain Injury (TBI) Care Conference Minutes Form

• Traumatic Brain Injury (TBI) Case Management Reporting Form

• Traumatic Brain Injury (TBI) Independent Living Assessment (ILA) Form

• Traumatic Brain Injury (TBI) Individual Service Plan Form

• Traumatic Brain Injury (TBI) Life Skills Aide Report Form

• Traumatic Brain Injury (TBI) Life Skills Aide Report Weekly Form

• Traumatic Brain Injury (TBI) Quarterly Report Form

• Triggers for High Need Wait List Referral for Clinical Review (CFC)

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U

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V

• Vermont Caregiver Registration Form

• Vermont Day Health Rehabilitation Services Prior Authorization Form

• Vermont Day Health Rehabilitation Services Prior Authorization From Instructions

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W

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X

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Y

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Z

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