Form 1074, Transition Support Teams (TST) - Case Review Request

Instructions

Updated: 2/2026

Purpose

The requester completes Form 1074, Transition Support Team Case Review Request, for a person who is at risk of institutionalization or losing community services. A team of multidisciplinary consultants uses the information on this form and any other supporting documents, if applicable, to coordinate a peer review or case consultation with the Service Planning Team (SPT) and collaborate on solutions for the person.

Note: If there are signs or symptoms of a medical or mental health crisis, immediately follow your Local Intellectual and Developmental Disability Authority’s (LIDDA’s) crisis protocol to coordinate emergency services and supports. Do not wait for a meeting with your Transition Support Team (TST).

Procedure

When to Prepare

This form should be completed before the potential risk of institutionalization or losing community placement is present, such as increasing medical, behavioral or psychiatric need, or before the consideration of a state supported living center (SSLC) placement. The LIDDA staff should monitor the person following the frequency required by the Person Directed Plan (PDP) and speak with service providers to assess risk factors.

Note: Exceptions to this requirement include emergencies, sudden onset of a medical or mental health crisis, behavior concerns or arrest. In these instances, the service coordinator may verbally request a TST consult and submit this form after making the request to ensure a quick response.

Detailed Instructions

Section 1 – LIDDA and Program Provider Information

Date – Enter the date the request is submitted.

LIDDA – Enter the name of the assigned LIDDA.

Program Provider – Enter the name of the program provider agency that is directing the person’s services.

Requester – Enter the name of the person making the request.

Title – Enter the requester’s official work title.

Area Code and Phone No. – Enter the requester’s work phone number.

Email – Enter the requester’s work email address.

Section 2 – Type of Service Request and Reason

Type of Service Request – Mark the requested activity.

• Peer Reviews are designed for LIDDA and provider staff to seek information or advice about a case-specific presenting issue. This may be the first step in seeking assistance with a specific case that should be followed by a Multidisciplinary Case Consultation. It may also be used for nonurgent situations where more support and planning are needed or may only require a specific team member’s expertise.
• Multidisciplinary Case Consultations are used when seeking assistance with a specific case when there are concerns about the person’s health, safety or an imminent risk of institutionalization. This is also an appropriate resource when preparing for a transition or diversion or when more support is needed following a Peer Review.
• Uncertain which type of case review is best but know assistance is needed.

Reason for Request – Check all that apply. If Other is chosen, document in a few words the reason for requesting the case review.

Brief Summary of Reason for Request – Briefly describe the primary reason the requester is seeking assistance from the TST.

For Transition Support Team (TST) Only

Completed by the contracted TST.

Received By – TST staff person’s name who received this form.

Date – Date received.

Contact Date – Date TST staff person contacted the requester following receipt of this form.

Staff Initials – Initials of the TST staff person who contacted the requester.

Section 3 – General Information

Person’s Name – Enter the name of the person for whom the requester is seeking a case review.

ZIP Code – Enter the ZIP Code where the person currently resides.

Date of Birth – Enter the person's date of birth.

Age – Enter the person's age.

Sex – Mark the person’s sex.

CARE ID — Enter the person’s assigned CARE ID.

Race or Ethnicity – Select the person’s identified race or ethnicity.

Religious or Spiritual Identity – Enter the person’s identified religion or spiritual preference.

Preferred Language – Select the one most closely associated with the person’s primary language, either spoken or understood. If Other, check the associated box and note their primary language.

Communication Method – Select the one most closely associated with the person’s primary mode of communication. If Other, check the associated box and note their most frequently used method of expressive language.

Guardianship Status – Mark the appropriate legal status. If applicable, confirm guardianship documentation is current.

Primary Contact – Enter the person’s primary contact and their relationship to them. This could be a parent, guardian, legally authorized representative (LAR) or someone else the person trusts. Make sure the primary contact has consent from the person to participate. Enter the primary contact’s current phone number and email address where they can be easily reached.

Service Coordinator – Enter the name of the LIDDA Service Coordinator.

Area Code and Phone No. – Enter the area code and phone number of the LIDDA Service Coordinator.

Email – Enter the email address of the LIDDA Service Coordinator.

How long has the requester known the person? – Enter how long the requester has known or worked with the person. If less than one year, enter the estimated number of days, weeks, or months, whichever is most appropriate.

Current Program – Mark the appropriate program:

• BH/MH = Behavioral Health/Mental Health    
• CFC = Community First Choice
• CLASS = Community Living Assistance and Support Services
• DBMD = Deaf Blind with Multiple Disabilities  
• ECI/ECSE = Early Childhood Intervention/Early Childhood Special Education, formally known as PPCD
• GR = General Revenue
• HCS = Home and Community-based Services
• ICF = Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions (ICF/IID)
• MDCP = Medically Dependent Children Program
• SSLC = State Supported Living Center
• SH = State Hospital
• STAR+PLUS HCBS = STAR+PLUS Home and Community Based Services, also referred to as STAR+PLUS Waiver
• TxHmL = Texas Home Living
• Other = document the most appropriate description

Current Residence – Check the box that best describes where the person currently resides. If Other, explain where the person lives.

Risk for Institutionalization or Losing Community Services – In the requester’s opinion, based on the person’s history, support system and current issues or concerns, rate the risk of the person being admitted to an SSLC, general or psychiatric hospital, nursing facility, or jail or otherwise losing their current community-based services or residence. The table is meant to guide the requester to determine the risk and does not capture all possible scenarios.

TST Case Review Severity Chart

Section 4 – Clinical Information

Behavior Concerns – Check all applicable concerns to the best of your knowledge.

Primary Diagnosis – The person’s primary diagnosis related to services, such as Mild ID. 

Secondary Diagnosis – The secondary diagnosis is a coexisting condition, such as a related condition if ID is the primary diagnosis or a diagnosed mental health condition. Not applicable is acceptable.

Medical Diagnosis – The medical diagnosis refers to identified conditions such as diabetes, heart disease or cancer. If there are no secondary or medical diagnosis, not applicable (NA) is acceptable.

Current Supports – Check all applicable paid supports.

Natural Supports – Check all applicable natural supports.

Last appointment date with medical professionals – Enter the dates for each medical appointment. Not applicable is acceptable.

Medications – If the person takes prescription or over-the-counter medication, vitamins or supplements, enter the name, dosage and times taken per day. If there are several, the requester may print out the person’s medication list and submit it with the referral form.

Does the person have a Behavior Support Plan (BSP)? – Check the appropriate box.

Date of last BSP assessment – Provide the date of the assessment.

Section 5 – Historical Information

Provide the most recent data for the following.

Date of most recent DID – Enter the date of the most recent Determination of Intellectual Disability (DID). Not applicable is acceptable.

IQ Score – Enter the IQ score documented in the most recent DID or psychological assessment if a DID is not yet completed. Not applicable is acceptable.

ABL – Enter the most recent adaptive behavior level (ABL) score from the most recent HHS approved assessment. Not applicable is acceptable.

Name of School or ISD – Enter the name of the school or school district and grade if they are currently enrolled in school. This includes higher education or vocational training. If the person is not attending any type of educational or vocational training, enter NA.

Is there a history of trauma or victimization – Mark Yes or No. If yes, select all known and self-reported events to the best of your knowledge.

Were there any significant changes or events in the last year – Mark Yes or No. If yes, mark all known and self-reported events to the best of your knowledge.

In the last year, were there any – Mark all events that occurred within the last 12 months. Enter the number of times each event occurred to the best of your knowledge.

Are other agencies involved? – Mark Yes or No. If yes, mark all relevant agencies currently involved.

• DFPS – Department of Family Protective Services, such as CPS, APS
• ECI/ECSE – Early Childhood Intervention/Early Childhood Special Education, formally known as PPCD
• LMHA/LBHA – Local Mental Health Authority or Local Behavior Health Authority
• TDCJ – Texas Department of Criminal Justice
• TJJD – Texas Juvenile Justice Department
• TWC – Texas Workforce Commission
• VA – Veterans Affairs
• DRTx – Disabilities Rights Texas
• The Arc – A local, state or national nonprofit organization that provides services, supports and advocacy
• Other – Document the most appropriate description

What has been tried so far? – Provide a summary of all attempts to find a solution to the reported concern(s).

What are their strengths and goals? – List the person’s known and self-reported strengths and goals.

Is there anything else the TST needs to know? – Using known information and monitoring services, provide any more information not already listed that may be important to assist the person or improve the current situation.

Multidisciplinary Case Consultations Only

Use this section as a checklist. Applicable documents are required when submitting this referral form to your TST and requesting a Multidisciplinary Case Consultation.

Supporting documents include: 

• Admission, Review and Dismissal (ARD),
• Individualized Education Program (IEP),
• 504 Plan,
• behavioral health records,
• behavior support assessment and plan (BSP),
• recent behavior data collection,
• Comprehensive Nursing Assessment (CNA),
• Crisis Intervention Plan,
• DID,
• Functional Behavior Assessment (FBA),
• ICAP,
• Intellectual Disability/Related Condition (ID/RC) assessment,
• LIDDA records, including:
  • service coordination notes,
  • medical records,
  • lab results,
  • list of medications,
  • Person Directed Plan (PDP),
  • Implementation Plan (IP),
  • Habilitation Service Plan (HSP),
  • provider records such as progress notes and medication logs, and 
  • psychiatric records.
• Provide any other relevant documents that may assist the consultation team, such as:
• crisis diversion or SSLC application,
• transition or diversion plan.

Submit the completed form to the TST for a Peer Review. Submit the completed form and applicable documents to the TST for a Multidisciplinary Case Consultation.