1d Proof

SPED 421: Family Resource Plan
2017
``For the Flying Cloud Family
Created on October 12, 2017
Review Due (6 months)

Created by: Amelia Huntsman, Alyssa Crockett, Lauren Pyper, Sydney Stamper

FAMILY INTRODUCTION
The Flying Cloud Family is a happy mixed family. Alex is Navajo Native American, and his
wife, Uriah is African-American. They are originally from Farmington, NM and both attended
San Juan College. Uriah received her associates and Alex received a bachelor's in engineering. It
was there that they were married and began their family.
Alex did not grow up on a Native American reservation, but his family lived near by. As a
consequence he spent much time there, learning about and being raised in a mix of cultures.
He was also raised Central Baptist, and remains a faithful member today.
Uriah, on the other hand, is an only child. She enjoys outdoor excursions and
appreciates cultural differences. She was also raised Central Baptist. These connections drew
them together.
When Alex was offered a job as an engineer at Boeing 3 years ago they relocated in
Seattle, WA with their only son, Timmy. Once there, Uriah started working as a secret shopper
around the area. Her job provides flexible hours and a welcomed additional income in addition
to Alex's.
As for raising Timmy they have chosen to attend church together, and are planning to
raise Timmy in the religion as well. Their religious beliefs affect their views on life and
interactions with others.
However, faith has wavered as Timmy began to show signs of disabilities. He was
developing typically but began having feeding issues as an infant. He is sensitive to food
textures, nor does he like to be held. This concerns the parents; as their only child they want to
snuggle with Timmy and show physical affection. However, they are unable to. They have
begun to note that he portrayed acts of aggression that are above children his age. This, of
course, worries them too and has become a strain on their marriage.
However, in their free time, to keep things as carefree as possible, the family enjoys
athletic activities such as pickle ball. For calmer activities they like family movie night and
reading novels. Individually as parents they will go out with groups of friends for lunch or a
night out, not only for fun but for emotional robust as well. Uriah has formed friendships with
some other women who attend their church, many of whom are also first-time mothers.

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SPED 421: Family Resource Plan 2017

FAMILY STRENGTHS
The family is strong in the Baptist faith. They do not attend church as often as they would like,
but have many good friends in their church community. Their beliefs provide them with a sense of
stability and certainty in life. They feel that they have a place of belonging, and a definite path to work
towards.
The family is financially stable, Alex has a good job and Uriah has flexible hours that allow her to
be home with Timmy. They feel they are able to provide for themselves well.
The parents communicate well and embrace their cultural differences. They strengthen each
other. While extended family lives in another state, they are very kind and supportive. They have
provided good advice for Alex and Uriah to help with their first child. They feel well equipped to raise
their child.

INFORMATION SUPPORT
1st Family Concern/Priority: The family needs information on behavior management strategies
that they can implement in their home.

Current Resource/Information: The family has tried different methods for helping Timmy to self-regulate
his emotions and behavior. Time-outs do not appear to calm his emotions.

Outcome: The family is will be able to find information to assist Timmy in regulating his emotions.

Suggested Action:
Resource Type and Name: Books and websites to assist Uriah, Alex, and Timmy.
1. “Self Regulation Intervention Strategies: Keeping the Body, Mind, and Emotions” By Teresa
Garland
2. “Tools of the Mind” by Deborah J. Leong and Elena Bodrova
3. “Sensory Integration and Self-Regulation” by Frances P Connor and Marie E Anzalone
4. “How to Be a Superhero Called Self Control” by Lauren Brukener
5. https://childmind.org/article/can-help-kids-self-regulation/
6. https://www.kidsmatter.edu.au/mental-health-matters/social-and-emotional-
learning/anger/explaining-self-regulation
7. http://day2dayparenting.com/help-child-learn-self-regulation/

Rationale: These books and websites will assist the parents in supporting Timmy by helping
them understand how they should act and how to help Timmy build self control.

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2nd Family Concern/Priority: The family desires to show physical affection; however, most physical
touch seems to quickly become overstimulating for Timmy. The family wants to show affection
through some form of touch while avoiding overstimulation for Timmy.

Current Resource/Information: Timmy is prone to overstimulation, and touch seems to cause an
adverse reaction. The family attempts to engage in brief physical contact. This is something that
Timmy is beginning to accept, although not consistently or for long periods of time.

Outcome: Timmy’s family will be able to develop a greater understanding of Timmy’s processing
issues, and develop more effective ways to interact with him.

Suggested Action: Uriah and Alex are to research the following websites in order to develop a
greater understanding of how to assist Timmy in daily life. They can study these to learn greater
sensory processing.

Resource Type and Name: This is a series of blogs and informational websites to assist the parents in
understanding and helping Timmy.
1. https://www.calminghugs.com/html/information.php
2. https://www.teachthought.com/pedagogy/5-ways-to-support-students-sensory-processing-
disorder/
3. https://www.iidc.indiana.edu/pages/Sensory-Integration-Tips-to-Consider
4. https://www.sensorysmarts.com/working_with_schools.html
5. https://www.todaysparent.com/kids/helping-kids-with-sensory-processing-disorder/
6. http://ilslearningcorner.com/2015-10-why-all-parents-and-teachers-should-read-sensory-
processing-101/
7. http://lemonlimeadventures.com/15-must-follow-sensory-blogs/
a. blogs
8. https://themighty.com/2015/07/for-moms-of-children-with-sensory-processing-disorder/

Rationale: These resources will help Timmy and his parents understand what might be going on with him
and help them discover strategies in helping him cope and live as typical as possible.

FORMAL SUPPORT
1st Family Concern/Priority: The family is hoping to see a greater variety in Timmy’s food palette,
and overall tolerance for different foods and textures.

Current Resource/Information: Timmy is sensitive to a range of particular food textures. He struggles to
keep down many foods. The family has tried to alternate diet and simple diet integration, but that has
not proven as effective as they have hoped.
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Outcome: The variety of food that Timmy is able to eat and tolerate will increase considerably.

Suggested Action:
Resource Type and Name: Southwest Pediatric Occupational Therapy, LLC
Contact Information:
o Phone number: 505-325-3039
o Location: 2901-A La Habra St Farmington, NM 87401
o Email: swpedsot@medsecuremail.com
Program information
o “We have been providing OT services to children on the Navajo Reservation since 1999.
These children have open and loving spirits and they continue to inspire us daily. We
feel very fortunate to be able to offer our services in such a unique setting. The schools
we serve are located across 3 states- AZ, NM and UT. They provide wonderful therapy
space and equipment that allow us to make a very real difference in the lives of children
with special needs. Our services consist of OT evaluation, IEP development, one: one
and group occupational therapy and consult OT, as well as parent and teacher training.
We host continuing education classes for parents and professionals several times a year
in Durango, CO.”
o “The therapists at Southwest Pediatric Occupational Therapy strive to provide the best
OT intervention possible. Although we primarily provide our services in a school setting,
we also offer MNRI® sessions to children and adults at our office in Farmington, NM.”
o “All of the therapists working with Southwest Pediatric OT have state licensure and
NBCOT certification, undergo state and federal background checks and keep up to date
with continuing education.”
o “Our mission is to help children with special needs to maximize their motor, cognitive,
social and emotional development through joyful learning and innovative therapeutic
intervention.”
Policy Information
o “We do not accept insurance for MNRI® sessions at our Farmington office. However, we
do offer discounted package deals for MNRI® sessions. The total cost for a 10 session
package can be paid when booking online or the decision to purchase a 10 session
package can be made at your first appointment. Save $150.00 by booking a package
deal today.”
o $75 an hour
o General operates within schools; however, in office visits are available as well.
Applications/Forms
o Occupational Therapy Questionnaire and Checklist
Child’s Name: ___________________________ Age: __________
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Preferred to be called ____________________________________
Diagnosis ______________________________________________
Parent’s Names: _____________________________
Parents Address:
___________________________________________________________
City ________________________ State ___________________Zip___________
Home Phone #___________________________________
Cell Phone #_____________________________________
Birthday _______________________________________ County of
Birth________________
Sex____________ Race: ______________________Marital Status _________ Pregnant
Y or N
Social Security Number: ________________________________________
Parents Employment : ( or employment if child is employed)
________________________________________________
(Circle all that apply)
Work full/Part time Retired Homemaker Unemployed Disability Student
Childs School: _________________________________________
Teacher’s Name: _______________________________________
Grade: ________________________________________________
Diagnosis: _____________________________________________
Physician: _____________________________________________
Insurance Type: ________________________________________
Spouse’s Name: _________________________________________
Spouse’s Date of Birth: ___________________________________
Spouse’s Employer ______________________________________
Reason for OT referral: ______________________________________
Parent’s concerns are:
_______________________________________________________________________
Current Equipment:
________________________________________________________________________
_
Does child have a history of seizures? _______
What is the protocol for seizure? _____________________________
Other precautions or allergies? ______________________________
Describe your child’s vision:
___________________________________________________________________
Describe your child’s hearing:
_________________________________________________________________
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As you answer these questions, please think of the various stages of your child’s
development considering any behavior which comes to mind.
*Were there times when your child’s behavior was difficult to cope with in the family
unit? Please explain.
• During the past month have you been feeling down, depressed, or hopeless? Y or N
• During the past month have you ever felt unsafe at home or has anyone hit you or
tried to injure you
in anyway? Y or N
• Is this something you would like help with? Y or N

The following questions are posed to help in compiling a more complete
picture of your child from early infancy to present developmental stage.
Some of the questions may refer to children who are older than your own.
Check the choice which applies: Yes or No.
Add narrative information which would be important in the comments section or on the
back please.
Mother’s Health during Pregnancy:
Yes No Comments
1. Have any infections/illnesses during pregnancy?
2. Have any shocks or unusual stress during pregnancy?
3. Water break more than 24 hours before delivery?
4. Develop toxemia/high blood pressure? If so When???
5. Have any complications during delivery and/or labor?
6. If premature, how early?
____________________________________________________________________
7. What was the child’s birth weight?
____________________________________________________________
8. Child’s weight when discharged from hospital?
_________________________________________________
9. Apgar Scores? 1 minute_________________________5
minutes__________________________________
Child’s Health at Birth:
1. Was child full term? Yes No Comments
2. Was child born cesarean section?
3. Did child breech? (feet first)
4. Cord wrapped around neck?
5. Were forceps required?
6. Did child have any birth injuries? ____________________________
7. Did child require a fetal monitor? __________________________
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8. Did child have insufficient oxygen?
9. Did child cry right away?
10. Did child require ICU hospitalization?
A. How long? __________________
B. Prematurity?
C. Respiratory problems?
D. Need respirator? How long? ______________________
E. Small for age?
F. Heart defect?
G. Require transfusion?
H. Jaundiced?
I. Have seizures?
J. Have infection at birth?
K. Have surgery as newborn?
L. Have feeding problems as newborn?
Developmental Milestones
1. Were feeding and sleeping patterns easily established? Yes or No. If no, Explain.
________________________________________________________________________
_____________________________
________________________________________________________________________
_____________________________
________________________________________________________________________
_____________________________
2. When did your child consistently sleep through the night?
3. Fussy baby past age of 6 months? Yes or No. If yes, Any reason identified?
________________________________________________________________________
_____________________________
________________________________________________________________________
_____________________________
4. Indicate child’s age for achieving the skill. If uncertain, indicate early, late, or typical:
_____ Independent sitting _____ hands/knees crawling _____ walking
_____ First words _____ sentences _____ toilet trained ______ ______
Day night
5. Do you think that any part of your child’s development is slower than average?
If yes, explain:
6. Current areas of concern (please mark all that apply):
____Gross Motor Development
____ Fine Motor Development
____Sleeping
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____Language Development
____Social Skills
____Eating
____Play Skills
____Temperament
____Frustrations (list):
____Fears (list):
____Independent living skills
Other:
7. When did you first notice your child's difficulties and how were they apparent to you?
8. Is there a family history of similar difficulties? If so, who, and what are the difficulties?
9. Please list any previous medical and/or diagnostic tests or evaluations (i.e.
neurological, genetic
testing, educational, speech/language, developmental, other) and their results. If
possible, please
attach copies of reports.
Significant test results: ______________________________________________
Any diagnosis given: _______________________________________________
10. Please check if your child has received services from any of the following:
_____Occupational Therapy ______Tutoring
______Physical Therapy ______Psychological Counseling
______Speech Therapy ______Special Education
If so, when, where (private or school), and for how long?
Are these services ongoing?
Medical and Behavioral History
Please indicate all that are applicable and ages(s):
_____ High fevers _____ Meningitis _____ Ear infections / tubes
_____ Chicken pox _____ Whooping cough _____ Heart trouble
_____ Mumps _____ Scarlet fever _____ Excessive vomiting
_____ Allergies _____ Seizures _____ Lung / bronchial difficulties
_____ Epilepsy _____ Diabetes _____ Surgery / hospitalization
Other significant accident, injury, or illness?
Please specify significant allergies or food restrictions:
Physical or medical precautions or activity restrictions (i.e. due to heart problems,
asthma, seizures,
Physical limitations, etc.):
Is your child currently on any medication? No _____ Yes _____ Purpose:
Names of medication, dosage, side effects:
________________________________________________________________________
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________________
________________________________________________________________________
________________
________________________________________________________________________
________________
Comments:
What are your child's most preferred activities/ favorite toys?
Indoors:
Outdoors:
What are your child's least favorite activities?
Indoors:
Outdoors:
When is your child most calm or happy?
_________________________________________________
When does your child become most frustrated?
____________________________________________
Does your child use a transitional object or security toy (bear, blanket, and pacifier)?
________________________________________________________________________
_
Does your child tend to have difficulty learning new motor tasks/games?
_____________________________________________________________________
Does your child resist participating in fine or gross motor tasks? Please explain:
________________________________________________________________________
__
Does your child have any recently acquired skills?
__________________________________________
Check the following items that best describe your child.
Visual
____ Wears glasses
____ has a diagnosed visual problem (describe):
____ Has difficulty finding / seeing things (shoes in the closet, toy in a toy basket)
Auditory and Language
____ Has a suspected or diagnosed hearing loss
____ Limited or absence of gesturing to assist communication
____ Excessive talking interferes with listening
____ Nonverbal; Do they have a form of communication? List/circle the form of
communication system
(PECS, Sign Language, gestures used, etc.):
If language is not strong, describe the vocalizations your child uses:
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Oral-Motor and Respiratory Control
____ Displays poor lip control / lip closure for eating, drinking, using utensils
____ Has limited skills with blow toys, whistles, bubbles
____ Demonstrates poor saliva control (drools)
____ Chokes easily on liquids or solids. Specify:
____ Overstuffs mouth with food
____ Clenches jaw or grinds teeth
____ Holds breath frequently
____ Breathes with mouth open / often has mouth open
____ Noisy breathing / snores
Comments:
Self-care / Regulation of Body Function
Is your child able to complete these tasks independently (please circle ( Y)es / (N)o)
__Y/N__ Toileting – bowel/ bladder control
_Y/N___ Undresses
_Y/N___ Dresses
_Y/N___ Snaps / Unsnaps
_Y/N___ Buttons
_Y/N___ Zippers pull / engage/ disengage
_Y/N___ Velcro on / off
_Y/N___ Socks on / off
_Y/N___ Self-feeding (finger foods)
_Y/N___Uses eating utensils
_Y/N___ Uses open cup
_Y/N___ Sippy cup
_Y/N___ Uses a straw
If your child has difficulty with controlling bowel and / or bladder (day or night or both),
please explain:
Additional comments:
Please provide any other information that you would like to share about your child.
Such as your goal out of therapy.
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Pamphlets/Handouts
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Rationale: Occupational Therapy can help with sensory and food processing disorders. It can provide a
safe space for persons with eating difficulties or disorders.

2nd Family Concern/Priority: The family is experiencing stress. Each family member is in need of support
both individually and as a whole.

Current Resource/Information: The family is trying to communicate with each other, and reaching out to
extended family on occasion. There is good communication between Timmy’s parents and the school he
attends.

Outcome: The family will see an increase in communication, and an overall greater sense of security.
Suggested Action: Timmy will attend individual counseling to help with self-regulation. Uriah, Alex, and
Timmy will attend family counseling together
Resource Type and Name: Desert View Family Counseling Services
8. Contact Information
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o Phone: 505-326-7878
o E-mail: INFO@MYDESERTVIEW.ORG
o 6100 E Main St, Farmington, NM 87402, USA
9. Program information
o “Desert View’s Healthy Kids Program provides clinical counseling for children who have
experienced abuse, incest, molestation, neglect, abandonment, medical trauma,
divorce, behavioral issues, and other types of trauma. We focus on improving the
psychological well-being of young children and strive to help them sustain healthy
relationships and improve family resiliency.
Our trained clinicians work with children ages 3-12, (with numerous child counseling
modalities) and their caregivers.
We offer the following services for children including Experiential Play Therapy,
Adolescent TheraPLAY and Caregiver Psycho-Education.”
o Family, Marriage, Individual, Couples
We offer a number of services for adults suffering from depression, anxiety and other
mood disorders. Some of the services that we provide include the following.

Depression
Feelings of hopelessness
Anxiety
Panic attacks
Insomnia
Fatigue
Racing thoughts
Acute stress

Grief
Loss and Bereavement

Communication
Marriage relationship
Affair, Affairs, Divorce
Family relationships
Extended Family issues
Social situation problems
Personality conflicts

Substance abuse and addiction
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Screening/Assessment
Early Intervention
Outpatient
Treatment aftercare

Sexual Orientation
Straight, Gay, Lesbian, Transgender, etc.
Couples counseling

Trauma
Physical Abuse
Sexual Abuse/Molestation
Stalking/ Harassment
Domestic Violence
Crime Victims
Accidents

Attention Concern & Other Disorders
A.A.D.D. Adult Attention Deficit Disorder
A.D.H.D. Attention deficit hyperactivity disorder
Bipolar Disorder Management
Adult R.A.D. Reactive Attachment Disorder

10. Policy Information
o A. It is required that you check in 10 minutes prior to a regular office visit. If you are
having an assessment done we may ask that you arrive 30 minutes prior to your
scheduled appointment time. We ask that you come in prior to your scheduled time so
that the appropriate administrative and clinical paperwork can be completed and ready
for your session. Failure to arrive at the requested time may result in cancellation of
your appointment.
o We serve families with in the context of their own family rules, traditions, history and
culture. The community-based in home service program is designed to help strengthen
families through compassion and respect. Service Specialists share with the community
the responsibility of keeping children and youth safe.
o Your first visit is usually initial paperwork called an “intake”.
o Once all intake paperwork and required testing is complete (anxiety and depression
scale) and a SASSI (substance abuse screening) the results will be analyzed, and then our
staff will schedule you an “assessment” appointment with a therapist, at which time
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they will sit down with you and discuss treatment options in detail.

11. Applications/Forms
o Paperwork required – You must bring in your Medicaid or Medicare (United Health
Medicare only) information if applicable or your current insurance card.
o Grant Assistance – Depending on your income or size of household, you may qualify for
our sliding fee scale or grant assistance. YOU MUST BRING IN PROOF OF INCOME TO
QUALIFY.
o Custody/ Guardianship – Children and adolescents must have a parent (or legal
guardian) present to sign for treatment. If parents are separated, going through a
divorce, or divorced then you must provide a “parenting plan”. If you are a foster parent
or legal guardian, then you must provide this documentation as well, no exceptions!
12. Pamphlets/Handouts
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Rationale: Counseling has the possibility to assist Timmy in regulating his emotions. It can help him learn
how to interact with others, and better handle episodes of anger when they happen. Counseling can also
help Uriah and Alex learn how to better support themselves, Timmy, and each other.

INFORMAL SUPPORT
1st Family Concern/Priority: The family is in need of childcare services for Timmy while Uriah is at
work.
Current Resource/Information: Uriah is unable to bring Timmy with her when she goes to work,
necessitating childcare services during the day. Timmy is old enough to enter preschool, rather than
having specific childcare.
Outcome: Uriah and Alex will be able to find an appropriate service to provide childcare for Timmy while
they are at work.
Suggested Action:
Resource Type and Name: (State) Cate Pre-K Elementary /Growing In Beauty
Contact Information
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o http://www.nnosers.org/growing-in-beauty.aspx
o http://preschool.fms.k12.nm.us/Home%20Page
o Andrea Garcia, Principal
o agarcia@fms.k12.nm.us
o 505-599-8625

13. Program information
o Cate partners with the Growing In Beauty program for Navajo Native American children
with disabilities. The GIB program helps to coordinate services and provides direct
services.
o “Farmington Municipal Schools does not discriminate nor tolerate harassment on the
basis of race, color, ethnicity, national origin, religion, gender, sexual orientation, age,
disability, marital status, genetic information or pregnancy in its educational programs,
services or activities, or in its hiring or employment practices; and it will take immediate
action to eliminate such harassment, prevent its recurrence, and address its effects.
● http://www.nnosers.org/uploads/files/New%20online%20referral%20form%201_8_16
%20fillable.pdf
o http://www.nnosers.org/2gib-az-nm-brochure.pdf
o
Rationale: Cate Pre-K and Growing In Beauty are both committed to providing education and services to
children. Growing in Beauty structured with the unique Navajo culture at its core, making it an excellent
choice for this family. The Growing in Beauty program works with the entire family to help the child
reach their full potential.
2nd Family Concern/Priority: Uriah does not have a social support system in place and is looking for
friends.
Current Resource/Information: Now that they have moved to a smaller community, Uriah does not know
where to find social support as a mother of a child with a disability.
Outcome: The purpose of this resource is to help Uriah to establish friendships within her community
with parents of children who are similar to Timmy.
Suggested Action:
Resource Type and Name: (Community) Support Group for families of children with autism/sensory
processing disorder
17. Contact Information
o https://www.facebook.com/autismspectrumspdnorthwestnm/
o https://www.facebook.com/groups/280356245648088/
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18. Program information: This is a community group in northwestern New Mexico to provide social
support and encouragement to families of children with autism and other sensory disorders.
o In order to join the group, individuals need to send a message to the group
administrator requesting to join.

Rationale: A group that shares a common experience can provide needed support and encouragement
for families that struggle with sensory disorders. Uriah and Timmy will both benefit from meeting and
interacting with peers who share similar experiences. This group can provide emotional support and
encouragement, information, ideas and strategies, as well as providing friendship for Uriah and Timmy.

MATERIAL SUPPORT
1st Family Concern/Priority: Timmy needs transportation to and from therapy.
Current Resource/Information: Uriah has a car but is often unable to drive Timmy to and from
appointments due to her work schedule.
Outcome: She would like to have a bus route, same as they had in Seattle, to bring Timmy to a from
school daily.
Suggested Action: Timmy and Uriah will have transportation to and from doctor and therapy sessions.
Resource Type and Name: Mobility Driven Adaptive Driving Solutions
Contact Information:
Address: 832 Nth Crest Grand Junction, CO 81506
E-mail: mobilitydriven@gmail.com
Telephone: 1.970.712.1435
● Program information: Helping to either transport resident around town or enable home vehicle
to be better suited to disability(s).
● Policy Information: “Only NMEDA Dealers offer individualized, in-person evaluations to
make sure you’re matched with the right adaptive equipment for you and your family.
Our membership organization of experienced mobility experts and Quality Assurance
Program™ (QAP) accredited technicians can help you find a van, car, truck or specialty
vehicle that fits your lifestyle. Our mobility equipment dealers offer wheelchair ramps,
hand controls and steering aids, transfer seats and seating solutions, wheelchair
securement and tie downs, scooter lifts and special acceleration and braking solutions
for adaptive vehicles. We are also able to provide you with 24-hour emergency service
and provide factory-supported warranties, all to ensure you’re safe and comfortable on
the road to independence.” (http://www.nmeda.com/)
● Applications/Forms: file:///C:/Users/hunts/Desktop/application%20for%20ESCE.pdf
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● Pamphlets/handouts (need out)
● Rationale: This company is beneficial because it provides one-on one care 24/7 for best
assurance of support and reliability.

2nd Family Concern/Priority: They are concerned about how to get setup with Medicaid or another
insurance to help provide for their sons needs. Uriah is unsure how she will pay for the services and
supports that Timmy needs. She doesn’t know what her resources are or where to begin looking.
Current Resource/Information: Alex recently lost his job and had to move them back to their hometown
in Farmington, Arizona. They aren’t sure what will be covered by insurance and what they will have to
cover. Uriah is not living with her husband and she does not have a high-income job. She works as a
secret shopper but that is not reliable.
Outcome: Find a support system that is both affordable and complies with Timmy’s needs.
Suggested Action: Health care that provides for disabilities and single mothers who live under or near the
poverty line.
22. Resource Type and Name: New Mexico Department of Health (https://nmhealth.org/about/)
23. Contact Information: https://nmhealth.org/contact/general/
24. Program information: medicare designed to assist families, with or without disabilities, while
living within their means as assisted by the government.
25. Policy Information:
Core Values
Vision
Our vision is for people with intellectual and developmental disabilities to live the lives they
prefer in their communities.
Mission
Our mission is to effectively administer a system of person-centered community supports and
services that promotes positive outcomes for all stakeholders with a primary focus on assisting
individuals with developmental disabilities and their families to exercise their right to make
choices, grow and contribute to their community.
Principles
Our guiding principles are as follows.
● Stay Results Focused
● Work for System Simplicity, Accountability, and Transparency
● Stay Person/Family Centered
● Use information wisely using Evidence-Based Practices
● Work in Partnership
● Promote Choice
● Emphasize Prevention
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Actions
We will put our guiding principles into action with these basic steps.
● Accountability – Demonstrate honesty, integrity and honor commitments.
● Communication – Promote trust through mutual, honest and open dialogue.
● Teamwork – Share expertise and ideas through creative collaboration to work toward common goals.
● Respect – Appreciate the dignity, knowledge, and contributions of all persons.
● Leadership – Promote growth and lead by example throughout the organization and in communities.
● Customer Service – Place internal and external customers first by assuring their needs are met.
https://nmhealth.org/about/ddsd/
26. Applications/Forms: https://nmhealth.org/publication/view/form/3882/

Effective 9/8/2017 REGISTRATION FORM – HOME AND COMMUNITY BASED WAIVERS AND
INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES (ICF/IID) Date of
Registration: For official use only Waiver or ICF/IID Options (check all that apply) Developmental
Disabilities (DD) or Mi Via Waivers Medically Fragile Waiver Intermediate Care Facility for Individuals
with Intellectual Disabilities (ICF/IID) DDSD staff entering registration in CR: date stamp Region: METRO
NERO NWRO SERO SWRO APPLICANT INFORMATION SEX Date of Birth Name – Last First Middle
Initial M F Social Security Number Street Address City State Zip Code Telephone Number Mailing
Address (if different from street address) City State Zip Code County Residence County in which services
are requested (if different from residence) Tribal Census Number (if applicable): First time applying?
Yes No Don’t know Currently receiving Medicaid? Yes No Currently receiving SSI/SSDI? Yes No
Developmental Disability and age of onset Name and relationship of individual submitting registration
form 1. LEGAL REPRESENTATIVE INFORMATION* Parent Legal Guardian Power of Attorney
Agency *Anyone other than the parent(s) of a minor child MUST include copies of documents that
provide evidence of legal authority to act on behalf of the applicant. Name – Last First Agency Name (if
corporate guardian) Street Address City State Zip Code Primary Telephone Number Mailing Address (if
different from street address) City State Zip Code Other Number 2. AUTHORIZED REPRESENTATIVE OR
ALTERNATIVE CONTACT* *Please ensure that an Authorization for Release of Information is provided for
this person. Name – Last First Relationship to applicant: Street Address City State Zip Code Primary
Telephone Number Mailing Address (if different from street address) City State Zip Code Other Number
Si necesita ayuda o información en español, por favor llámenos al numero 1-800-283-5548. If you are a
person with a disability and you require this information in an alternative format or require a special
accommodation to participate in registration or services, please call us at 800-283-5548 or, through the
New Mexico Relay System TDD, at 1-800-659-8331. (printing this out)
27. Pamphlets/Handouts: http://www.gcd.state.nm.us/intellectual-and-developmental.aspx

Rationale: This health care provides assistance to disabled and family in need.

Please check one and sign below:
I agree to the above stated plan
I agree to the above stated plan with the following changes (see attached addendum sheet)
21 | Page

I do not agree to the above stated plan and refuse all services and supports

Parent/Legal Guardian print name Parent/Legal Guardian print name

Parent/Legal Guardian signature Date Parent/Legal Guardian signature Date

Service Coordinator Signature Date
22 | Page

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SPED 421: Family Resource Plan

26. Applications/Forms: https://nmhealth.org/publication/view/form/3882/

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