TX HHS Form 5150. Family Service Plan

This document provides a structured support plan for children who are blind or visually impaired and their families. Form 5150 is used by the Division for Blind Services (DBS) to outline goals, services, and responsibilities that help a child build independence, develop core life skills, and explore early vocational interests. Although the form appears administrative, it serves as a roadmap that coordinates multiple agencies and specialists working together to support a child’s development.

Purpose of Form 5150

The form establishes a formal Family Service Plan that defines what types of services a child will receive, who will provide them, and how progress will be monitored. It ensures that the child’s developmental and vocational needs are addressed through coordinated support, rather than through isolated activities or disconnected programs.

In practice, this document prevents service gaps by placing medical specialists, educational partners, community resources, and DBS personnel on the same page — literally. Parents gain clarity on what to expect, what is required of them, and what steps will follow over the year.

Key Sections Explained

Core Services Overview

The form lists the full range of services a child may access, including:

• Counseling and family guidance
• Training for daily living, mobility, communication, and self-care
• Coordination with school districts and early childhood intervention programs
• Assistive technology and adaptive equipment
• Travel and child-care assistance to access services
• Case management and referrals
• Diagnostic and restoration services

Each service type supports the broader goal of helping the child move toward independence and self-sufficiency.

Goals Section

The plan organizes objectives into several developmental categories:

• Adjustment to Blindness
• Independent Living
• Travel Skills
• Communication Skills
• Support Systems
• Vocational Discovery and Development

For each category, there are fields for objectives, projected timelines, required services, and the responsible provider. This structure helps families clearly understand what their child is working on and how progress will be measured.

Service Provider List

The form identifies potential collaborating agencies, such as:

• DBS specialists
• Early Childhood Intervention Services
• Children with Special Health Care Needs Services Program
• Local education agencies
• Community organizations

These partners contribute medical, educational, and social resources. Families often misunderstand this section and assume they must contact all providers themselves — but in reality, DBS coordinates most inter-agency communication.

Progress Monitoring and Review

Progress reviews occur several times per year and include input from the family, specialists, educators, and medical professionals. Reassessment is required at least annually, ensuring the plan reflects the child’s evolving needs.

Responsibilities and Contact Requirements

Parents or guardians agree to:

• Participate actively in scheduled services
• Notify DBS about income changes or updated contact information
• Use comparable benefits when available (for example, school-based services)

DBS agrees to maintain regular contact, typically several times annually or more frequently if needed.

When This Form Is Required

This form is necessary whenever a child who is blind or visually impaired receives ongoing developmental and vocational services through DBS. It is not required for single, one-time consultations or isolated equipment requests. A formal plan is needed when services span multiple skill areas, involve more than one provider, or require ongoing monitoring.

Legal and Regulatory Context

The Texas Government Code (Sections 552.021, 552.023, and 559.004) gives families the right to review personal information collected by DBS and request corrections when needed. Form 5150 helps DBS demonstrate compliance with these requirements by clearly documenting services and responsibilities.

Additionally, program funding rules require the DBS specialist to authorize services before payment can be issued. The plan serves as part of that authorization process.

Typical Mistakes Families Make

• Leaving objectives too vague (e.g., “improve communication”) instead of specifying measurable goals
• Not updating income information, which may affect eligibility for funded services
• Assuming the school handles all mobility or communication training — DBS provides additional support
• Failing to document outside services, leading to duplicated or conflicting interventions

Practical Tips for Filling Out Form 5150

• Be specific when describing objectives; the clearer the goal, the easier it is for providers to tailor support.
• List all ongoing therapies and school-based services so DBS can coordinate properly.
• Ask the children’s specialist for examples of strong objectives if unsure how to phrase them.
• Submit documentation for recent assessments — they speed up service authorization.
• Keep a copy of the completed plan for future reference during progress reviews.

Real-Life Examples

• A 4-year-old who recently lost vision needs orientation and mobility training, along with parent counseling to help the family adjust.
• A school-age child transitioning to a new district requires coordination between DBS and the local education agency to update assistive technology needs.
• A teenager preparing for summer work programs may need vocational exploration, communication skills training, and travel instruction.
• A child with additional health conditions may receive simultaneous support from medical specialists and community programs, all documented through Form 5150.

Documents Commonly Required

• Recent medical or vision assessments
• School or early childhood evaluation reports
• Assistive technology recommendations (if applicable)
• Proof of income for determining eligibility for purchased services

FAQ

• How often is the plan reviewed? Reviews occur several times per year, with a required full reassessment annually.
• Does the plan replace school services? No. It supplements educational programs by adding DBS-specific support.
• Are all listed services guaranteed? Services depend on eligibility and available funding, and must be pre-authorized.
• Can objectives be changed mid-year? Yes. If the child’s needs change, families may request an update.
• Is parent participation required? Yes. Many services depend on active family involvement.
• Do families pay for services? Some services may be income-dependent; others are provided at no cost.

Micro-FAQ (Short Answers)

• Purpose: To outline services supporting development and early vocational skills.
• Who completes it: Parents/guardians and a DBS children’s specialist.
• Deadline: At program entry and reassessed annually.
• Attachments: Assessments, evaluations, and income documentation.
• Submitted to: Division for Blind Services.
• Required for: Ongoing, multi-service developmental support.
• Can it be revised: Yes, if the child's needs change.
• Is funding guaranteed: No — all services depend on eligibility and available program resources.
• Does it include school services: School programs are coordinated but not replaced.
• Is parent participation needed: Always.

Related Forms

• DBS Initial Assessment Form
• Early Childhood Intervention Referral Form
• Assistive Technology Service Request
• Independent Living Skills Training Plan

Form Details

• Form Name: Vocational Discovery and Development Family Service Plan
• Form Number: 5150
• Agency: Division for Blind Services (DBS)
• Region: Texas
• Revision Date: May 2017