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Ward's Social Conditions, Education, Services and/or Employment

Please answer the following questions about the Ward's social conditions.
Required fields are marked with an

I am taking or have taken the following actions to encourage the development of maximum self-reliance and independence:
Is able to participate in activities? Yes No

If yes, list IP’s activities (social, recreational, family, educational, job):

If no, explain why cannot participate:

List Supports(family,friends,community/religious groups):

I believe has unmet social needs: Yes No

If yes, what is being done to address those needs?

Is diagnosed with Intellectual/Developmental Disability? Yes No

Go to:

Progress: 0% complete

Protective Orders: Family Law Center, 200 East Weatherford Street #3040 Fort Worth, Texas 76102
Telephone: 817-884-1623 Fax: 817-212-7393 e-mail: pounit@tarrantcountytx.gov

MHMR Tarrant County Yes No	Service Coordinator:
CLASS/Easter Seals Yes No	Contact Person:
HCS Yes No	Agency Name:
TxHML Yes No	Agency Name:
MDCP Yes No	Agency Name:
Texas Workforce Commission Yes No	Case Worker:
ISS Yes No	Name of Program:

Medicaid Yes No	Name Of Managed Care Company:
Private Insurance Yes No	Name Of Company:
MHMR Behavioral Health Yes No	Case Worker:
Home Health Yes No	Name of Agency:
Privately Paid caregiver/service Yes No	Name/Type:
Other Yes No

What supports and/or services have been discontinued and why:

Services applied for , but that were denied:

TARRANT COUNTY, TEXAS

Ward's Social Conditions, Education, Services and/or Employment

TARRANT COUNTY, TEXAS

School Name:
School Location:

Employer:
Days/Hours Worked:
Length of time employed here: