Form 1701, Support Plan Narrative

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Effective Date

9/2025
1701.pdf , 1701-s.pdf

Instructions

Updated: 9/2025

Note: A member as defined in 15 Texas Administrative Code (TAC) Section 353.2 is referred to as a person in this form. A Medicaid applicant is also referred to as a person in this form.

Purpose

Form 1701 is completed for a person being assessed for either the STAR+PLUS Home and Community Based Services (HCBS) program or Community First Choice (CFC) services. The form collects narrative information about the person to inform the services and supports he or she receives.

A person enrolled in the Home and Community-based Services (HCS), Texas Home Living (TxHmL), Community Living Assistance and Support Services (CLASS) and Deaf Blind with Multiple Disabilities (DBMD) waivers will not use this tool. Existing tools used in these waivers are used to assess for CFC services.

Form 1701 is:

  • developed through a person-centered planning process;
  • completed with the support of others chosen by the person, with support from the legally authorized representative (LAR) if applicable; and
  • completed in a way that accommodates the person's style of interaction, communication and preferences for time and setting.

Form 1701 is used to:

  • identify the person’s strengths, preferences, support needs and goals;
  • identify what is important to the person;
  • identify and document the person’s current and preferred living arrangement;
  • identify natural supports available to the person;
  • identify any needs, requests or considerations staff should know when supporting this person;
  • describe how to meet the person’s needs and whom to contact in case of an emergency;
  • determine if the person’s current living situation meets the federal requirements for HCBS settings; and
  • document any modifications to the HCBS settings requirements for a person receiving services in provider owned or controlled settings.

Procedure

When to Prepare or Update

Form 1701 is part of the STAR+PLUS HCBS individual service plan (ISP). For a person applying for STAR+PLUS HCBS the MCO completes it. For a person eligible for CFC services and at least annually for a person receiving STAR+PLUS HCBS or CFC services the MCO or LIDDA completes it. The form is also updated whenever the person’s needs have substantially changed.

Moving forward, assessor is the MCO or LIDDA completing the form.

The information in this form is obtained through an information gathering conversation called the discovery process. It is about the person’s abilities, preferences and goals, in line with person-centered planning principles. The assessor should move through the various sections of the form following the natural flow of the conversation with the person and LAR, if applicable, and should re-visit completed sections if more information emerges as the discovery process continues.

The assessor must ask the person or LAR, if applicable, every question that appears on Form 1701 unless otherwise indicated on Form 1701 or in the form instructions. The assessor’s observations cannot be substituted for the person’s response but can be recorded in Section 9: Service Coordinator Comments. If the person does not use words to communicate, the assessor must facilitate communication sufficient for the person to respond to the questions on Form 1701. Every field on Form 1701 must be completed unless otherwise indicated on the form or in the form instructions. If a person or LAR does not know the information requested or declines to answer, document that in the space provided.

Form Retention

Each MCO must keep Form 1701 per the retention requirements found in all Medicaid managed care contracts and federal regulations. Keep all originals or electronic copies of this form in the applicant's or member's folder or electronic record for five years after services are denied or terminated.

The LIDDA must keep the original copy of the form in the individual's case record and provide a copy to the MCO.

The LIDDA must keep Form 1701 per the retention requirements found in the LIDDA Performance Contract and state and federal regulations.

Detailed Instructions

My Legal Name - Enter the person’s legal name.

I Like to Be Called - Enter the name or nickname the person prefers to be called, if different from his or her legal name.

Person’s Medicaid No. – Enter the person’s nine-digit Medicaid number.

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

Date of Completion – Enter the date the form is completed.

Event Type – Indicate if this narrative is initial, a renewal or a revision.

Section 1 – Individual Strengths and Preferences

Discuss the questions with the person and record their answers. Use the prompts on the form as a starting point for further conversation. The service coordinator can also record input from the LAR, if applicable, or others the person has invited to participate in the service planning meeting.

Insert Photo Here (optional) – If available, insert one or two recent photos of the person or photos of people, places or things that are important to him or her. This is optional but provides more information about the person.

What people like and admire about me – Document what the person likes about him or herself, as well as what others say they like about him or her. Document what the person wants others to know about him or her.

What's important to me – Important to reflects what is important from the person’s perspective and is based on conversation with or observation of the person. The information might include important relationships, how the person prefers to interact, things the person likes to do or not do, preferred routines, relevant background information and what the person wants to do in the future. Remember the person’s response is limited to the knowledge and experiences he or she has to date. Effort should be made to increase the person’s awareness of more possibilities and experiences to increase his or her options of choice.

What others need to know and do to support me – Important for reflects information that is important for the service provider to know and understand about health, safety and any supports necessary for the person to live the life he or she wants and be a valued member of the community. Document how the person communicates and prefers others to communicate with him or her. Enter information such as health needs, supervision requirements, specific behavioral needs, and special instructions for those who support the person. This section includes contraindications and special justifications for deviating from typical routines or activities. For example, this could include day activity health services three days a week, four hours a day, or a job four days a week, five hours a day. Things identified as important for are not usually included as important to the person.

What the people are like who support me best – Document the characteristics and traits that the person finds most supportive. Some examples are someone with a gentle voice who enjoys the same activities as the person or preference of a male or female attendant. Also document traits that the person finds unsupportive. Provide any information that may be important to a successful match between the person and the service provider.

How I like to spend my day - Document what the person prefers to do during the day, including but not limited to:

  • daily routines and rituals;
  • places he or she likes to go;
  • how he or she relaxes;
  • holidays he or she likes to celebrate; and
  • any other activities he or she enjoys.

Also document other activities the person would like to start or do more often.

Other things about myself – Record biographical information about the person here. Also use this space to record any other information the person says is important to know about him or her that is not captured by the questions above.

Section 2 – Goals or Desires

This section documents the person’s goals or desired outcomes and the strategies and supports needed to achieve each goal.

Goal or Desired Outcome: Goals or desired outcomes are identified by and unique to the person. They can be medical or nonmedical, including personal, educational and social goals or outcomes, and can be short- or long-term. The assessor can use the terms goal or outcome interchangeably depending on what is most meaningful, understandable and useful to the person.

Examples of goals and outcomes include:

  • Learning how to play the guitar
  • Meeting new people in the community
  • Getting a job at a beauty supply shop
  • Staying out of the hospital
  • Learning to use the city bus system and riding the bus alone
  • Maintaining close friendships from the person’s school days
  • Taking a trip to the Grand Canyon

As the assessor, person and LAR, if applicable complete other parts of this form, information and patterns may emerge that indicate a goal or outcome needs to be recorded. For example, if the person states in Section 4 that he or she currently lives with a relative but wants to move into his or her own apartment, the assessor should record this as a goal in Section 2. The assessor and person can and should move freely between sections of the form to record any goals identified when discussing other subjects.

Example Form 1701 entry: I want to get a job in the next year.

Barriers to Achieving Goal or Desired Outcome: Identify any barriers that must be addressed for the person to achieve his or her goal or desired outcome. Barriers include, but are not limited to:

  • Transportation
  • Communication
  • Awareness of options
  • Access to and use of technology
  • Health factors
  • Community factors

Example Form 1701 entry:

Goal: I want to get a job in the next year.

Barriers:

  • I do not know what kind of jobs I would like to do or be good at doing.
  • I need help to apply for jobs online because I sometimes have trouble using the computer.
  • I do not have a mode of transportation because I cannot drive a car or ride a bicycle.

Strategies: Work with the person to define strategies that will lead to achieving each goal or desired outcome. Strategies:

  • Are specific.
  • Detail actionable steps and assign responsibilities to specific people within the Medicaid applicant or member’s support system to take towards meeting the goal.
  • Identify the actions the service coordinator will take to help the person achieve each goal.
  • Specify what the person and his or her support system need to observe to track progress.
  • Are tailored to the person’s preferences and capabilities.
  • Provide clear criteria for tracking progress, ensuring both the person and his or her support system can effectively monitor advancements over time, and make adjustments based on changing circumstances.

Example Form 1701 entry:

Goal: I want to get a job in the next year.

Strategies:

  • My service coordinator and I will complete the Employment First Discovery Tool together to determine what types of jobs I will apply for.
  • My service coordinator will help me:
    • get approved for employment assistance services;
    • invite Michael, my mother and Ellen to my service planning meeting and discuss how they will support me in finding a job; and
    • find bus routes to the Texas Workforce Commission office and job interviews.
  • I will contact the Texas Workforce Commission in the next month to get help applying for a job.
  • I will apply for one job a week for the next three months.
  • I will meet with my primary support person every two weeks to monitor my progress in getting a job.

Supports Needed to Achieve Goal or Desired Outcome: List people and other supports who will help the person reach this goal or outcome, including the service coordinator’s role. Other supports can include community programs, resources through the person’s school and religious groups. Document any barriers that might make meeting goals difficult for the person such as community or health factors, and how they can be overcome.

Example Form 1701 entry:

Goal: I want to get a job in the next year.

Supports Needed:

  • My friend Michael will help me use the computer to apply for jobs online.
  • My mother Delores will help me mark down job interviews on my calendar.
  • My CDS employment assistance provider Ellen will meet with me every two weeks to monitor my progress in getting a job and will contact Vanessa if needed.
  • My service coordinator Vanessa will check in with Michael, Ellen, my mother and me monthly and answer any questions we have.
  • The Texas Workforce Commission will advise me on different career paths and open job postings.
  • The city bus will be my mode of transportation to the Texas Workforce Commission office and job interviews.

Detail the plan to assess progress toward meeting established goals, including a time frame for follow-up to communicate with the person: Together with the person, create a plan to follow up on progress towards each goal or desired outcome. The time frame for follow up:

  • May differ between goals, even for the same person, due to factors including:
    • The person’s priorities
    • External deadlines
    • Strategies used to meet the goal
    • Individualized barriers to meeting the goal
  • Includes dates the service coordinator follows up with the person to discuss progress made toward achieving the goal.
  • May be more frequent, but no less frequent, than the annual re-evaluation of the ISP.

Section 3 – Important People in the Person’s Life

Does the person have a legally authorized representative (LAR)? Check the box showing if the Medicaid applicant or member has an LAR. If he or she has an LAR, document the type of legal authority this person has, if there is current legal paperwork on file, and the expiration date of the paperwork. If current legal paperwork is not on file, document the reason for this.

Current Providers: List the names and contact information for the person’s currently known providers including primary care provider, individual or company providing home health, personal assistance service, physical therapy, occupational therapy, adult day care, respite care, meal delivery and transportation services.

People Who Are Important to Me: List the people the Medicaid applicant or member is close to and cares about. This will help the provider determine whom to speak with in certain situations. It will also help to ensure that the Medicaid applicant or member does not lose contact with important people in his or her life.

Also use this table to document current and future availability of paid or unpaid caregiver supports provided by family, friends, and other community members. This includes people who will assist the applicant or member with activities of daily living (ADLs) and instrumental activities of daily living (IADLs).

Additional rows may be added if necessary.

Name — Enter the name of a person who is important to the Medicaid applicant or member or who will provide help or services to the Medicaid applicant or member during the ISP period.

Relationship — Enter the relationship between the Medicaid applicant or member and the person who is important to him or her or will provide help or services to him or her during the ISP period.

Phone Number, Address and Email — Enter the area code and phone number, address and email address of the person who is important to the Medicaid applicant or member.

Is this person providing informal support(s) in lieu of paid services? — Check the correct box to indicate if the person who is important to the Medicaid applicant or member provides unpaid services or supports that supplement or replace services or supports that would otherwise be paid for.

Important Because —

Document why the person who is important to the Medicaid applicant or member is important to him or her. If the person who is important to the Medicaid applicant or member provides informal unpaid services or supports, document the service(s) provided by the person who is important to the Medicaid applicant or member and document specific detail of what is included in the service(s).

Examples unrelated to unpaid informal services and supports include:

  • He is the person’s father.
  • She is the person’s best and oldest friend. They have known each other since pre-school.
  • She is the person’s favorite teacher.
  • He and the person like to go to Sunday brunch together every week.
  • The person spends every holiday vacation at his house.

Examples related to unpaid informal services and supports:

  • The person’s wife reminding the person when to take his medications and at what dosages.
  • The person’s son visiting for dinner every night to prepare food, help the person eat and prevent the person from choking.
  • The person’s co-worker giving her a ride to and from work.
  • The person’s roommate helping her with personal hygiene.
  • The person’s friend helping the person learn steps to use the washing machine.
  • The person wants to attend a regular church event in the future, and the Bible study lead will coordinate a schedule to provide transportation.

Units or Hours per Week — If the person who is important to the Medicaid applicant or member provides informal unpaid services or supports, enter the units or hours per week the service(s) will be provided. A single number indicating the total units or hours per week of all services provided is sufficient. Units and hours do not need to be broken down by individual service.

Involved in Development of Plan? — Check the appropriate box to indicate if the person who is important to the Medicaid applicant or member was involved in the development of the plan.

Check this box if no informal unpaid support is available — Check the box if no informal unpaid support is available. The term available refers to informal unpaid support that a person can access for help. If there are friends, family members or community members who are willing and able to provide help with daily activities or other care needs without compensation, then that support is considered available. If such informal support does not exist, or if there are individuals who could provide support but are unwilling to do so, check the box showing that there is no informal unpaid support available.

Section 4 – Living Situation

Current Residence – Check the most appropriate box from the list to show where the person currently lives.

Own Home or Apartment

  • Alone – Check this box if the person lives alone. This includes a person living alone who receives in-home services.
  • With spouse, partner or relative – Check this box if the person lives in his or her own home with a spouse, partner or relative. If the person lives with a spouse, partner or relative who is being paid, this box should be checked.
  • With non-relatives or roommates – Check this box if the person lives with a non-relative or with other roommates. This includes if the person lives with a caregiver who is paid or unpaid, or if the person lives in a dorm or community living situation.

Someone Else’s Home or Apartment

  • Relative – Check this box if the person lives in a relative’s home. The relative may be a paid or unpaid support providing services such as personal care to the person.
  • Non-relative – Check this box if the person lives with a non-relative who may also be the person’s caregiver who is paid or unpaid but is not living in the person’s own home or relative’s home.

Residential Setting

  • Assisted Living Facility (ALF) – Check this box if the person lives in an ALF.
  • Adult Foster Care (AFC) – Check this box if the person lives in an AFC home.

Institution

  • Nursing Home – Check this box if the person lives in a nursing home as his or her permanent residence. If the person is currently in a hospital or nursing home for rehabilitation, but maintains a home elsewhere, do not select this box. For example, if the person is in the nursing facility for rehabilitation but has an apartment that he or she intends to return to, then the apartment is the current residence. The person’s permanent living arrangement should be indicated rather than the temporary setting.
  • Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions (ICF/IID) – Check this box if the person lives in an ICF/IID facility. This includes state supported living centers (SSLCs).
  • Institution for Mental Disease (IMD) – Check this box if the person is currently living in an IMD, including a state psychiatric facility.

Other Living Arrangements

  • No Permanent Residence – Check this box if the person does not have a permanent residence and specify the person’s living arrangement. For example, check this box if the person lives in an emergency shelter. A hotel or motel would go under no permanent residence if it is a temporary arrangement. If the hotel or motel serves as the person’s permanent residence, select one of the options under the Own Home or Apartment category.
  • Other–Specify – Check this box only if no other box is appropriate and specify the person’s living arrangement.

Is this living situation:

  • Permanent – Check this box if the person plans to stay in this living arrangement for the foreseeable future and if this living arrangement is available to the person for the foreseeable future.
  • Temporary – Check this box if the person’s current living arrangement will not be available to him or her in the future or if he or she is currently in the process of changing his or her living arrangement. Record the end date of the person’s current living arrangement. If the exact date is unknown, provide the most accurate timeframe possible.

If you need to provide more information about the person’s living arrangement, document this in Section 9: Service Coordinator Comments rather than choosing other when an existing option would be appropriate.

Who chose your current living arrangement? Ask the person if he or she chose his or her current living arrangement by himself or herself, or if someone else helped or chose for him or her. Check the appropriate box to show the person’s answer. If someone else helped or chose for the Medicaid applicant or member, record that person’s name.

Were you given a choice between all the residence types listed above? Ask the person if he or she, or the person who chose his or her current living situation, was offered a choice between all the residence types listed in the Current Residence sub-section under the:

  • Own Home or Apartment;
  • Someone Else’s Home or Apartment;
  • Residential Setting;
  • Institution; and
  • Other Living Arrangements headings.

Check the appropriate box to show the person’s answer. If the person answers no, record the reason.

Were you given the option to live in a non-disability specific residence? Ask the person if he or she, or the person who chose his or her current living situation, was given the option of a non-disability specific living arrangement. Check the appropriate box to show the person’s answer. If the person answers no, record the reason.

Prefers to Live – Check the appropriate box or boxes from the list to show the person’s preference about where he or she lives. The Prefers to Live question asks for the person’s own stated preference. It is used to determine if the person lives where he or she wants to live and to track changes over time. Note: Record where the person would like to live, not where anyone else wants the person to live, and not where others think is realistic. Explain each different type of living arrangement to help the person understand his or her options.

Own Home or Apartment

  • Alone – Check this box if the person wants to live alone. This includes a person who prefers wants to live alone and who may receive in-home services.
  • With spouse, partner or relative – Check this box if the person wants to live in his or her own home with a spouse, partner or relative. This could be with a spouse, partner or relative who is being paid.
  • With non-relatives or roommates – Check this box if the person wants to live with a caregiver who is paid or unpaid, or to live in a dorm or community living situation.

Someone Else’s Home or Apartment

  • Relative – Check this box if the person wants to live in a relative’s home.
  • Non-relative – Check this box if the person wants to live with a non-relative who may also be the person’s paid or unpaid caregiver but is not in the person’s own home or relative’s home.

Residential Setting

  • Certified or Licensed Group Home – Check this box if the individual wants to live in a group home. This includes if the individual prefers to live in a three- or four-person residence operated by a certified HCS program provider.
  • Assisted Living Facility (ALF) – Check this box if the person wants to live in an ALF.
  • Adult Foster Care (AFC) – Check this box if the person wants to live in an AFC home.

Other Living Arrangements

  • No Permanent Residence – Check this box if the person wants a non-permanent residence and specify the person’s preferred living arrangement. For example, check this box if the person prefers living in an emergency shelter.
  • Other–Specify – Check this box only if no other box is appropriate and specify the person’s preferred living arrangement.
  • Unable to determine person’s preference for living arrangement – Check this box if you cannot determine the person’s living preference due to such things as challenges with communication or cognitive ability.

If you need to provide more information about the person’s preferred living arrangement, document this in Section 9: Service Coordinator Comments rather than choosing other when an existing option would be appropriate.

What is the LAR’s preference for living arrangements for this person? – Check the appropriate box or boxes from the list to show the LAR’s preference for where the person lives.

  • Not applicable – There is no relative or LAR, or the relative or LAR does not have any preferences around the person’s place of residence.
  • Stay at current residence
  • Move to own home or apartment which includes living with spouse or relative, non-relatives and caregivers
  • Move to an ALF which includes all size ALFs
  • No consensus among multiple parties
  • Someone else's home including the home of a relative, non-relative or caregiver

Is there anything else you want to tell me about your living arrangement? Record the person’s answer.

Is there anything you want to change about your living arrangement? Record the person’s answer.

Are there any of the following home safety risks? Ask the person if any of the safety risks listed on the form are present in his or her home. The service coordinator can include his or her own observations along with the person’s stated answer. Specify if the home safety risks are permanent or temporary, and document the end date, if known. Document details of all home safety risks in Section 9: Service Coordinator Comments.

Section 5 – How I Spend My Day

Discuss paid employment, volunteerism, retirement or unemployment, education and other activities with the person. Use the prompts on the form to encourage and guide discussion. If the person does not currently do one of the activities being discussed and does not want to, record this in the corresponding box. If the person states he or she currently works or would like to work, the box for retirement and unemployment will not be completed, and vice-versa. The service coordinator may insert information documented on Form 8401, Employment First Discovery Tool where appropriate and if the person has already completed it.

Section 6 – Emergency Plan

Describe the details of the emergency plan or back-up plan — Enter specific detail of how the person’s needs will be met if there is an emergency. Emergencies include but are not limited to:

  • a behavioral health crisis;
  • serious injury;
  • extreme weather;
  • the provider not able to physically access the person due to physical obstructions;
  • temporary or permanent loss of caregiver.

The emergency plan includes actions to take in a weather emergency, such as required use of a ventilator and power generator backup and required emergency medication such as insulin and EpiPen. It also includes a listing of any life-threatening conditions the person has.

Include an emergency plan in the event the caregiver or the paid provider is unavailable. Because this situation is possible for any person, every person will have an emergency plan addressing, at minimum, actions to take if the caregiver or paid provider is unavailable.

Emergency contacts — Enter the name, relationship, area code and phone number of the people the Medicaid applicant or member would like the service coordinator to contact in an emergency. Emergency contacts could include family members or a trusted person who does not live with the Medicaid applicant or member.

The service coordinator must ensure the person has a physical copy of the emergency contact information described above. The physical copy given to the person must also include, at a minimum, the name and direct phone number of the service coordinator and appropriate provider staff to contact in an emergency.

Section 7 – HCBS Settings Requirements

Ask the person the questions in this section and record his or her responses.

Section 8 – Provider Owned and Controlled Settings

This section is only completed for a person receiving STAR+PLUS HCBS program services in provider owned and controlled settings, including but not limited to adult foster care (AFC) and assisted living facilities (ALF).

Provider Owned and Controlled HCBS Settings Requirements: Ask the person the questions in this sub-section and record his or her responses.

Modifications: HCBS settings requirements can only be modified for a person receiving services in a provider owned and controlled setting, and in those cases, only the requirements under 42 CFR 441.301(c)(4)(vi)(A) through 42 CFR 441.301(c)(4)(vi)(D) can be modified. Modifications must be applied to one person only. They cannot, for example, be enacted for all persons living in a single residential setting. Modifications can be enacted only with consent of the person or LAR. If a person is subject to multiple modifications, each is recorded and consented to separately.

If a modification will be enacted, select the checkbox showing this.

Clearly state the specific modification to the HCBS Settings Rule: Specify what action needs to be taken to ensure the person’s health and safety.

Identify which right this modification restricts: Select the checkbox corresponding to which right the modification restricts.

Identify the specific and individualized assessed need: Enter the person’s specific need prompting the modification. Do not enter a diagnosis.

How was the need assessed? Specify the mode in which the need was identified. This includes observations, assessment tools, or other modes. If a specific assessment tool was used, enter the name of the tool here.

Describe the health and safety risk caused by the assessed need: Describe the adverse result for the person if the modification is not approved.

Document the positive interventions and supports used before any modifications: Describe analytic methods and behavioral interventions implemented to help reduce challenging behaviors and to support and reinforce the learning of new, more appropriate behavioral skills.

Document less intrusive methods of meeting the need that have been tried but did not work. Explain why they did not work: Elaborate on analytic methods and behavioral interventions implemented to help reduce challenging behaviors and to support and reinforce the learning of new, more appropriate behavioral skills.

Describe how data will be collected and reviewed regularly to measure the ongoing effectiveness of the modification. Specify what data points will be collected: The person and service planning team will create a plan for collecting and monitoring data. Data can be both quantitative and qualitative. The data collection or monitoring plan should include:

  • Frequency of data collection
  • Method of data collection
  • Who will collect the data
  • The source of the data
  • Methodology for data monitoring
  • What data would need to be observed to minimize or lift the modification
  • A plan to adjust if the data shows the modification is not effective

What is the frequency of review to determine if the modification is necessary? Enter the time intervals for the service planning team to review progress and determine if the modification is still necessary. These time frames are determined by the service planning team. Time frames may happen more often, but not less, than the annual re-evaluation of the ISP.

Describe how the provider will mitigate the impact of the intervention on the person: List:

  • specific actions the provider will take to lessen the impact of the modification on the person’s rights and daily life;
  • ways that individual safety is considered; and
  • if the person had choice in determination of the modification.

Informed consent of the person: Review the statement of informed consent together with the person and LAR, if applicable. Answer any questions the person has. Ensure the person knows he or she is not required to consent to the modification and will not be subject to retaliation if he or she does not consent. Also explain to the person that not consenting to the modification may mean not being able to receive his or her current services safely in his or her current living arrangement. He or she may need to select a different living arrangement or different services.

If the person or LAR agrees with the statement and consents to the modification, select the checkbox indicating this. The person or LAR consents to and initials each modification separately.

Section 9 – Service Coordinator Comments (if applicable)

Document any other information the person would like the service coordinator, service providers, informal supports, and others to know to best support him or her.