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First Resources Corp.

A Resource For The Community

Intensive Residential Service Application

**Each question within this application must be fully answered.

Applicant Information

(If homeless or in a facility, please list last known address)

Will the individual be Court Ordered to Intensive Residential Services?
Do they have a guardian?

Applicant Screening Questions

The individual has three or more areas of significant impairment in activities of daily living or instrumental activities of daily living.
The individual is in need of 24-hour supervised and monitored treatment to maintain or improve functioning and avoid relapse that would require a higher level of treatment.
The individual has exhibited a lack of progress or regression after an adequate trial of active treatment at a less intensive level of care.
The individual is at risk of significant functional deterioration if Intensive Residential Services are not received or continued.
The individual has record of three or more psychiatric hospitalizations in the 12 months preceding application for Intensive Residential Services.
The individual has a record of more than 30 medically unnecessary psychiatric hospital days in the 12 months preceding application for Intensive Residential Services.
The individual has a record of more than 90 psychiatric hospital days in the 12 months preceding application for Intensive Residential Services.
The individual has a record of three or more emergency room visits related to psychiatric diagnosis in the 12 months preceding application for Intensive Residential Services.
The individual is residing in a state resource center and has a Serious & Persistant Mental Illness (SPMI).
The individual is being served out of state due to unavailability of medically necessary services in Iowa.
The individual has a Serious & Persistent Mental Illness (SPMI) and is scheduled for release from a correctional facility or a county jail.
The individual is homeless or precariously housed.
If the individual is accepted to services, will they be prepared to be admitted to Intensive Residential Services within four weeks (28 days) or less?

In order to make a complete referral to Intensive Residential Services, the following items will need sent:

  1. Standard functional assessment and screening for multi-occurring conditions completed 30 days or less prior to this application (SIS, LOCUS and CASH).

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  1. Diagnostic Records to include evidence of diagnosis of a Severe & Persistent Mental Illness (SPMI) or multi-occurring conditions.

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  1. Authorization showing the highest rate of home-based habilitation or the highest rate of HCBS intellectual disability waiver supported community living.

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If you are unable to upload documents

Please send all referral documents in one email, if possible, to: irshreferrals@firstresources.us

First Resources Corp. | Burlington, IA | P: 641-682-8114

Your application has been successfully submitted. Our referral team with be in contact with you soon!

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