HENDERSON HALL EFMP: PCS NEEDS ASSESSMENT

Sponsor
Name: / Sponsor Name / Rank: / Rank / DoD ID #: / Sponsor DoD ID
Email: / Sponsor Email / Cell Phone: / Sponsor Cell
Spouse
Name: / Spouse Name / Is Spouse an Exceptional Family Member (EFM)? / Yes/No
Email: / Spouse Email / Cell Phone: / Spouse Cell
Family Members
Name / Is Family Member an EFM? / Gender / DOB (mm/dd/yyyy)
1 / Family Member Name / Yes/No / M/F / mm/dd/yyyy
2 / Family Member Name / Yes/No / M/F / mm/dd/yyyy
3 / Family Member Name / Yes/No / M/F / mm/dd/yyyy
4 / Family Member Name / Yes/No / M/F / mm/dd/yyyy
5 / Family Member Name / Yes/No / M/F / mm/dd/yyyy
6 / Family Member Name / Yes/No / M/F / mm/dd/yyyy
Installation Information (If known)
Current Location: / Henderson Hall / PM*: / Mike Flaherty / FCW**: / Family Case Worker
Gaining Location: / Gaining / PM*: / Program Manager / FCW**: / Family Case Worker
Effective
Date of orders: / Date / Estimated
Date of Departure: / Date / Estimated
Date of Arrival: / Date
EFMP
Question / Please choose / If yes please comment
1 / Does your enrollment need to be updated? / Yes/No / Comment
2 / Would you like more information about EFMP/disability resources? / Yes/No / Comment
3 / Are you familiar with Marine & Family Programs/MCCS? / Yes/No / Comment
4 / Would you be interested in a special needs support group? / Yes/No / Comment
EFMP (Continued)
Question / Please choose / If yes please comment
5 / Would you be interested in participating in EFMP recreational activities? / Yes/No / Comment
6 / Do you plan to participate in the Respite Care Reimbursement Program? / Yes/No / Comment
Housing
Question / Please choose / If yes please comment
7 / Will your family be requesting installation or Public Private Venture (PPV) housing? / Yes/No / Comment
8 / Does your family qualify for priority housing? / Yes/No / Comment
9 / Does your EFM require accommodations or modifications for housing? / Yes/No / Comment
10 / Have you already applied for housing? / Yes/No / Comment
11 / Do you have any pets? / Yes/No / Comment
12 / Do you have any service animals? / Yes/No / Comment
Travel
Question / Please choose / If yes please comment
13 / Do you have a “Plan my Move” calendar? / Yes/No / “Plan my Move” can be found at:
www.militaryonesource.mil/moving
Comment
Medical
Question / Please choose / If yes please comment
14 / Are all medication prescriptions filled w/refills? / Yes/No / Comment
15 / Do you have copies of your EFM’s medical records? / Yes/No / Comment
16 / Have you transferred your TRICARE Region? / Yes/No / Comment
17 / Have you transferred your Tricare and/or ECHO Case Manager? / Yes/No/NA / Comment
18 / Do you have the gaining location doctors established? / Yes/No / Comment
19 / Will you need doctor appointments within 30 days of your arrival? / Yes/No / Comment
School
Question / Please choose / If yes please comment
20 / Do you have a Special Care Organization Record (SCOR) notebook? / Yes/No / SCOR can be found at: www.militaryonesource.mil/efmp/special-care-org-records
Comment
21 / Is your SCOR notebook up to date? / Yes/No/NA / Comment
22 / Do you have current copies of IFSP/IEP or 504s? / Yes/No/NA / Comment
23 / Does the current school district provide any assistive technology services, devices or other specialty adaptive equipment to your EFM? / Yes/No/NA / Comment
24 / Does the gaining school district have the current IFSP/IEP or 504? / Yes/No/NA / Comment
Services
Question / Please choose / If yes please comment
25 / Is your EFM receiving Supplemental Security Income (SSI)? / Yes/No / Comment
26 / Have you submitted a change of address for SSI payments? / Yes/No/NA / Comment
27 / Is your EFM receiving Medicaid? / Yes/No / Comment
28 / Do you need information on applying for Medicaid at your new location? / Yes/No / Comment
29 / Is your family receiving WIC/Food Stamps? / Yes/No / Comment
Child Care
Question / Please choose / If yes please comment
30 / Do your child(ren) need a child care provider? / Yes/No / Comment
31 / Will your child(ren) be participating in the Child, Youth & Teen Program (CYTP)? / Yes/No / Comment

Please return completed form to your EFMP Family Case Worker.

Questions? Contact your EFMP Family Case Worker at 703-693-4172/6510.

Exceptional Family Member Program, Henderson Hall

Marine & Family Programs, Bldg. 12, 1555 Southgate Rd., Arlington, VA 22214

Email: Website: www.mccshh.com/EFMP

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April 2013