PCSP Assistant Pro | Marion County DMH

1 Demographics / Contributors Information / Legal Demographics

Identity

Full Legal Name

Preferred Nickname

Date of Birth

DMH ID Number

TCM Agency

DMH Office Type

Office Location / County

Marital Status

Voter Registration Status

Religion

Religion — Other (specify)

Ethnicity / Race (select all that apply)

Communication & Language

Native / Primary Language

Additional Languages (Fluent)

Primary Communication Method

Insurance & Benefits

Primary Medical Insurance

Spend Down Monthly Amount

Private Insurance Provider Name

Dental Insurance

Dental Insurance — Other (specify)

Residency

Residential Setting (Missouri)

Residence Address / Location Notes

Legal Representatives / Guardians / Custodians

Education

School Name (Last / Current)

Education Status

Employment

Employment Status

Job Title / Employer / Description

System Integration Dates

Last Assessment Date

Last LOC Date

RAS Score

2 Communication

Language

Primary Language

N/A

Uses Sign Language?

Type of Sign Language

Sign Language Type — Other (specify)

Method of Communication

Communication Evaluations

Evaluation(s) Needed?

Communication Chart Not Applicable

No communication entries added. Click below to add one.

3Preferences, Likes & Special Interests / Dislikes

Things the Individual Likes / Enjoys

Favorite Activities & Hobbies

Favorite Foods / Snacks

Favorite Places / Outings

Other Likes / Preferences

Things the Individual Dislikes / Finds Upsetting

Activities / Situations Disliked

Foods Disliked

Other Dislikes / Things to Avoid

4 Important People

List family members, friends, staff, and others who are meaningful to this individual. Include what they enjoy doing together and how often.

No people added yet. Click below to add someone important to this individual.

5 Vision for a Good Life

Hopes, Dreams & Aspirations

Former Goals & Progress

How to Support These Vision Outcomes

Personal Strengths & Assets

MAAS / Vineland / MOCABI Limitations

Rituals & Routines

Religious Supports

Individual Preference for Staff

Support in All Aspects (School, Work, Home)

How the Individual Learns Best / Learning Style

Select Learning Styles...

Learning Style Notes

Cultural Differences

Regulate Water Temperature?

6 Health, Safety & Risk Planning

Medical Profile & History

Primary & Secondary Diagnosis

Personal Outcomes (Discovered during assessment)

HRST Status (If Waivered)

Telehealth Used? (Waivered Only)

Medical History / Traumatic Stressors

Prevention & Providers

Primary Care Physician (PCP)

Specialists (Dental, Vision, etc.)

Prevention (Diet, Exercise, Screenings)

Medications & Health Protocols

Current Medications (Name, Dosage, Purpose)

PRN Psychotropic Protocol (If Applicable)

Self-Administration of Meds

Health Parameters to Track

Select Parameters...

Known Health Risks & Emergency Planning

Identified Health Risks

Evacuation / 911 Plan

DNR / CPR Status

Provider Risk Level

Supervision Level

Behavioral Support

Staff Precaution (OSHA 3148)

Allergies / Sensitivities

7 Legal, Rights & Satisfaction

Legal Authority Roles

Select Authority Roles...

Limited Guardianship / Authority Details

Rights Brochure Addressed?

Consents on File?

Satisfaction with Services (Spelled out by service)

Conflict of Interest Info Provided?

Rights Limitations & Due Process No active limitations

Due Process Meeting Invitation

Description of Limitation

Less Intrusive Methods Tried (HCBS Requirement)

Historical Pattern / Source of Data

Teaching & Support Strategies

Measurable Criteria for Lifting

Monitoring & Data Collection

Compliance Note: Plan must include assurance that interventions cause no harm and information regarding the right to appeal to the Office of Constituent Services.

8 Contributors & Administration

Plan Effective Date

Annual Review Due Date

Waiver Type

Plan Contributors (Who was involved?)

Participation Statement

SC Visit Frequency

Payee / Monthly Spending Info

Burial Info (Placement only)

9 Measurable Outcomes Generator