The purpose of this survey is to identify barriers to accessing Children’s HCBS. Care managers should use this survey to report issues to the State – this survey does NOT need to be completed for all Children’s HCBS referrals, only when referrals are not successful. Reporting these access issues will help the State identify systemic issues and where additional supports may be needed.

Care managers should complete the survey in real time, one for each provider that has a waitlist and/or other access issue. Care managers may indicate if there are access issues with more than one service and/or for more than one referral but should complete a separate survey for each provider incident.

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* 1. In which county are you currently experiencing an access issue for Children’s HCBS?

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* 2. What is the name of the Children’s HCBS provider with which you are experiencing access issues?

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* 3. Please indicate the access issue and number of impacted referrals for each Children’s HCBS for this provider.

  What is the access issue you are currently experiencing? How many referrals are impacted by this issue for this service?
Caregiver Family Supports & Services
Pre-vocational Services
Community Advocacy Training & Support
Supported Employment
Palliative Care: Pain & Symptom Management
Palliative Care: Bereavement
Palliative Care: Massage Therapy
Palliative Care: Expressive Therapy
Respite: Planned
Respite:  Crisis
Day Habilitation
Community Habilitation

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* 4. How often have you attempted to contact the HCBS provider to resolve the issue?

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* 5. Have you previously experienced access issues with this provider?

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* 6. Please provide any further details related to the Children’s HCBS access issue you are currently experiencing.

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