Request for Supports Intensity Scale-Adult Version (SIS-A®) Needs Assessment

Scheduling Form for the Supports Intensity Scale (SIS®) Needs Assessment
The Supports Intensity Scale (SIS®) Needs Assessment has been used as a person-centered planning tool in the Commonwealth of Virginia for many years. The SIS does not focus on identifying an individuals’ deficits, but rather on identifying the supports an individual needs to achieve their goals. The tool was developed by the American Association on Intellectual and Developmental Disabilities (AAIDD).

The SIS focuses on the strengths of people, not their challenges. To schedule a SIS, please complete the secure scheduling form within 2 weeks of receiving it. Public Consulting Group (PCG) will reach the identified contact to schedule the assessment.

Please note: All Respondents are expected to stay for the duration of the assessment. If the individual chooses not to stay for the duration, arrangements must be made however, the Assessor must be able to see/interact with the individual at the beginning of the assessment.

For additional information, please visit:

https://www.aaidd.org/sis/sis-a/sis-a-resources

https://dbhds.virginia.gov/wp-content/uploads/2023/05/DBHDS-SIS®-Standard-Operating-Procedures-and-Review-Process-4.28.2023.pdf

Individual Information

This is the person receiving HCBS services and is required to have a SIS assessment.
Name of Individual*

First NameMiddle InitialLast Name
Phone Number of Individual
Please enter a valid phone number.
Email of Individual

Confirmation EmailPlease enter the email address twice for validation.
Date of Birth of Individual *

Month DayYear
CSB Tracking #
Does the individual have a Medicaid ID#?*
Enter Medicaid ID#*
Does the Individual have a legal guardian?*

YesNo
Legal Guardian Contact Information*
Address of Individual

Street Address

Street Address Line 2

CityState

Zip Code
Primary Language
Please specify in the Accommodations field at the end of this form if an interpreter is needed.
County of Residence

Supports Intensity Scale (SIS) Assessment Information
Setting Preference

Preference of the Individual
Please select the Individual's setting preference for the assessment*

VirtualIn Person
Please select a location to conduct the assessment*
Please enter the full address of the assessment location*
Please select a virtual platform to conduct the assessment*

ZoomMicrosoft Teams
Is communication assistance needed?

YesNo
Please describe the necessary communication assistance.

Support Coordination Information

Public Consulting Group (PCG) will call the Support Coordinator listed below to schedule the assessment. The call will come from 276-230-0056.
Support Coordinator (SC) Staff Name*

First NameLast Name
Support Coordinator Phone Number*
Please enter a valid phone number.
Support Coordinator Email*

Confirmation EmailPlease enter your email twice for validation.
Support Coordination Agency*
Support Coordination Agency Address
Support Coordination Agency Address Horizon Behavioral Health
Support Coordination Agency Address Rappahannock Area CSB
Support Coordination Agency Address Loudoun County
Support Coordination Agency Address Blue Ridge
Support Coordination Agency Address Dickenson
Support Coordination Agency Address Mount Rogers
Support Coordination Agency Address New River Valley
Support Coordination Agency Address Planning District One
Support Coordination Agency Address Southside
Support Coordination Agency Address Crossroads
Support Coordination Agency Address Middle Peninsula-Northern Neck
Support Coordination Agency Address Richmond Behavioral Health
Support Coordination Agency Address Colonial Behavioral Health
Support Coordination Agency Address Eastern Shore
Support Coordination Agency Address Hampton-Newport News
Address (if not listed above)
Secondary Support Coordinator (if applicable)

Add A Secondary Support Coordinator?
Secondary Support Coordinator Name*

First NameLast Name
Secondary Support Coordinator's Email*

Confirmation EmailPlease enter the email twice for validation.
Secondary Support Coordinator's Phone Number*
Please enter a valid phone number.
Name of Person to be Contacted Day of Assessment (if the same as the SC info entered above, leave blank)

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com

Respondents (Please read the instructions below)

Who will be participating in the SIS assessment with the Individual? If you are completing this form and will be participating in the assessment, please list yourself as a Respondent below. All active supporters (Waiver service providers) must be invited, listed as respondents, and must make every effort to attend and expect to stay for the duration of the assessment. All Respondents must have known the individual for at least 90 days and have observed and supported the individual closely in multiple environments for substantial periods of time.
Respondents:*

Specific Instructions to Assessor (including accommodations, interpreter needs, trigger words or actions, harmful behaviors to self or those around, pets in the home, any personality conflicts with respondents, parking instructions at the agency, etc.)
Respondent Team Availability (days/times) *Notes to SCs: Coordinating with members of the respondent team to enter mutual availability is preferred and will expedite the scheduling process. SIS assessments should not be considered scheduled until the Respondent Team receives an Outlook invitation via email from the Scheduler.
Should be Empty:

Scheduling Form for the Supports Intensity Scale (SIS®) Needs Assessment

Individual Information

Supports Intensity Scale (SIS) Assessment Information

Setting Preference

Support Coordination Information

Respondents (Please read the instructions below)