Get Hi Ancillary Service – One-to-one (1:1) Request Form 2018-2025

Filling out the HI Ancillary Service – One-to-One (1:1) Request Form online is a straightforward process that ensures the necessary support for youth is adequately requested. This guide provides step-by-step instructions to help you complete the form accurately and effectively.

Follow the steps to successfully complete the online request form.

1. Click the ‘Get Form’ button to access the HI Ancillary Service – One-to-One (1:1) Request Form and open it in your preferred editor.
2. Begin by filling out the youth information section. Provide the youth's name, customer ID, and date of birth.
3. In Section 1, as the requesting agency, describe the clinical justification for the service. Detail the behaviors of concern and the goals to be addressed with One-to-One support.
4. Next, outline the clinical plan. Describe the interventions the paraprofessional will implement to tackle the identified behaviors and goals.
5. Indicate the requested number of hours of support per day, keeping in mind the maximum limit of eight hours.
6. Specify the requested duration and the times of day when this extra support will be available.
7. Complete the 'Completed By' section, including your email, signature, title, agency name, phone number, fax number, and the date of completion.
8. In Section 2, the Clinical Lead should indicate their support for the need for One-to-One assistance and confirm agreement with the proposed plan to support the youth.
9. If there is a plan to decrease hours, briefly describe it in the specified section.
10. Provide the requested start date, ensuring to give at least 48 hours' notice to the Central Services Organization (CSO).
11. The Clinical Lead should then sign and date the form.
12. In Section 3, the CSO Resource Manager will recommend approval of the hours requested, duration, and start date.
13. Finally, review the completed form for accuracy and save your changes. You may then download, print, or share the form as needed.

Encourage others to complete their documents online for efficiency and ease.