TX HHS Form 2059-W. Summary of Individual's Need for Service Worksheet

The TX HHS Form 2059-W, Summary of Individual's Need for Service Worksheet, is a practical tool designed to help assess an individual's functional limitations and identify their needs for service delivery. This form is typically used in situations where an individual requires assistance with daily living activities or has specific medical conditions that impact their ability to perform certain tasks.

The form asks the individual to report any medical conditions that cause functional limitations, such as physical disabilities, cognitive impairments, or behavioral problems. It also requests information about the individual's home environment, including whether it is equipped with basic amenities like electricity, heat, water, and plumbing. Additionally, the form inquires about the individual's living arrangement, household/caregivers, and common household tasks being purchased.

Key features of this form include the required reporting of medical conditions and functional limitations, as well as the identification of specific problems that impact service delivery. The form also asks for information about assistive devices used by the individual and other agencies serving them. By completing this form, individuals can help healthcare providers and social workers better understand their needs and develop effective service plans.

• This form is typically used in situations where an individual requires assistance with daily living activities or has specific medical conditions that impact their ability to perform certain tasks.
• The form asks for information about the individual's medical conditions, functional limitations, home environment, and household/caregivers.
• This form is designed to help healthcare providers and social workers develop effective service plans for individuals with specific needs.