1. LTSS Screen Tell us about the individual’s needs
Has an intellectual disability (IQ is less than 70).
Has an autism spectrum disorder.
Has dementia (not able to think clearly), Alzheimer's disease, a brain injury, or other cognitive impairment.
Needs help with daily living needs such as bathing, dressing, eating, shopping, laundry, or making meals.
Cares for someone with one or more of the conditions listed above (a. to d.) and doesn't get paid to give care.
Gets care from someone who: (1) helps with daily living needs such as bathing, dressing, eating, shopping, laundry, and making meals, and (2) doesn't get paid to give care.
Has or had a mental health diagnosis.
Lives alone or doesn't have anyone to call for help in case of emergency.
Has a physical disability (for example, can't walk, can't see, or can't hear) and needs help paying for items or services needed for medical reasons.
Has or had a diagnosis of alcoholism or drug abuse.

2. LTSS Screen
Do you have any questions about Medicare or private long-term care insurance?
 Yes  No  No answer
Have you dropped many activities and interests lately?
 Yes  No  No answer
Do you feel full of energy?
 Yes  No  No answer
How many times in the past 12 months have you had 3 or more drinks of alcohol in a single sitting? □ 0 □ 1 □ 2 □ 3 □ 4 □ 5 or more
If you can't get care at home, how likely are you to move into a nursing home?
 Very likely  Likely  Somewhat likely  Not likely  A nursing home is not an option that is being considered  No answer

3. LTSS Screen Does Homer think it is wonderful to be alive now?
 Yes  No  No answer
During the past 30 days, has Homer taken any of the following? (check all that apply)
□ Medicines for pain or problems like back pain, muscle pain, headaches, arthritis, or fibromyalgia. Don't count: (1) vitamins, (2) herbs, (3) natural remedies, or (4) over-the-counter medicines such as aspirin, ibuprofen, TYLENOL, Advil, or Aleve.
□ Medicine for diabetes.
□ Medicine to help with sleep. Don't count: (1) vitamins, (2) herbs, (3) natural remedies, or (4) over-the-counter medicines such as melatonin, Benadryl, TYLENOL PM, or Advil PM.
□ Medicine for anxiety, nerves, or emotional upset. Don't count (1) vitamins, (2) herbs, (3) natural remedies, or (4) over-the-counter medicines.
□ Medicine for heart disease or high blood pressure.
□ Alcohol - beer, wine, wine cooler, or hard liquor.

4. LTSS Screen Do you feel that your life is empty?
 Yes  No  No answer
Programs you think might help.
Learn more about these programs at Most of these programs have an interest list. Check all that apply. If you're not sure about a program, check it anyway:
Helps older adults and people age 21 and older with disabilities get support services in a home setting. (STAR+PLUS Waiver)
Helps people living in certain Texas areas get support services. See the list of areas. (Program for All-inclusive Care for the Elderly - PACE)
Helps people with developmental disabilities get support services. (Community Living Assistance and Support Services Waiver - CLASS)
Helps get support services for people who: (1) are deaf and blind, and (2) have another disability that keeps them from living on their own. (Deaf Blind with Multiple Disabilities Waiver - DBMD)
Helps get support services to families who are the main caregivers for children and young adults who need help with their medical care. Helps the child or young adult with: (1) moving from a nursing facility to a home setting or (2) staying in a home setting. (Medically Dependent Children Program - MDCP)

5. LTSS Screen
You told us that you take care of someone. Could you use help? Help can include: (1) getting a short break - respite services, (2) helping you learn more about giving care, or (3) telling you about other support services.
   Yes  No  No answer
 The person you care for has:
Dementia (can't think clearly), Alzheimer’s disease, brain injury, or other cognitive impairment.
Another disability.
Tell us more about the person you care for:
 Their age
 Their relationship to you
 Do they live with you?
 Yes  No  No answer