Form 8647, Service Coordination Assessment – Intellectual Disability Services

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Effective Date

7/2026
8647.pdf

Instructions

Updated: 7/2026

Purpose

Form 8647, Service Coordination Assessment is completed for applicants and people enrolled in:

  • the Home and Community-based Services (HCS) and Texas Home Living (TxHmL) Programs;
  • General Revenue (GR) Services;
  • Enhance Community Coordination (ECC); and 
  • Non-waiver Community First Choice (CFC).

Use Form 8647 to: 

  • Determine if a person is eligible for service coordination. This only applies to people who want to receive GR-funded service coordination.
  • Identify the frequency for in-person contact. The minimum required frequency of in-person contact is every 90 days or more frequently, depending on each program's requirements. 

In-person, or in person, means within the physical presence of another person. In person does not include audio-visual or audio-only communication.

Do not use this form to determine frequency for Enhanced Community Coordination (ECC) contacts. The ECC coordinator must perform monthly contacts regardless of the results of this assessment. 

The ECC coordinator must complete the Work and School Domain in Section 2 – Assessment, specifically to determine a person’s interest in employment. 

When to Prepare

Complete Form 8647 at enrollment and annually. Updates to the form must occur when the person’s needs significantly change or if the frequency of in-person contact changes. 

Detailed Instructions

Section 1 - Person’s Information 

Name of Person — Enter the person’s first and last name. 

CARE ID No. — Enter the person’s Client Assignment and Registration (CARE) identification number.

Address (Street, City, State, ZIP Code) — Enter the person’s residential address. Include street, city, state and ZIP code.

Area Code and Phone No. — Enter the person’s contact phone number with area code. 

Name of LIDDA — Enter name of LIDDA where the person is currently assigned.

Section 2 - Assessment 

Each assessment area has three parts: 

  • Considerations
  • Assessment questions
  • Ratings

Considerations 

Considerations are questions to think about when completing this assessment. Documentation of answers to this section’s questions could be in the person’s:

  • record; 
  • progress notes; or 
  • the person’s plan of services, such as the Person-Directed Plan (PDP).

Assessment questions

There are two types of questions for each domain: 

Yes or No –   Answer each question with either yes or no. You can select Not Applicable if it is available. 

Checklist – Check all items in the list that are applicable to the person. Only check Not Applicable if none of the items listed are relevant to the person. 

You must complete and consider each question when rating the assessment. 

Ratings

Rate each domain based on the interview with the person and their legally authorized representative (LAR) if applicable. Think about the consideration and assessment questions when rating each domain. 

General rating descriptions: 

A 3 rating means the person is in a life-threatening situation that may also significantly impact health or safety. This situation must relate to this domain.

A 2 rating means the person is trying to access services and supports. This may include a change in need or services, but does not rise to concerns about health, safety or crisis. 

A 1 rating means the person may have services and supports in place. A service coordinator is desired to monitor services and supports to make sure they stay in place so the person is successful. 

A 0 rating means the person does not need help, services or supports for this domain. 

More rating information is in each domain. 

Rights and Legal Status

Helpful information: 

Physical Health

Helpful information:

Centers for Disease Control and Prevention (CDC) states, Chronic Diseases are defined broadly as conditions that last 1 year or more and require ongoing medical attention or limit activities of daily living or both.

Chronic diseases include heart disease, cancer, diabetes, Alzheimer’s disease or other dementias, COPD and stroke.

Emotional and Behavioral Health

Example ratings:

Rating 3: Crisis referrals, court or jail involvement, frequent psychiatric hospitalizations or rehab for drug use.

Rating 2: The person needs a Behavioral Support Plan.

Rating 1: The person has behavioral services or a behavior support plan in place that has worked well for over one year. They are stable on all psychotropic medications.

Independent Living

Helpful Information: 

Transportation resources: 

Medical Transportation Program

Call 211 or visit the 211 website to search for transportation resources in your area.

Example ratings:

Rating 3: The person is homeless and has no family to live with, needs help modifying their living environment to meet health, safety or physical needs. They do not have sufficient income to meet current needs or have no income, bills are due and they are in danger of eviction.

Rating 2: May need help locating and applying for new housing and accessing community resources and services during moves. May need help locating or accessing transportation. Desires help modifying the living environment known as Minor Home Modifications. Needs extensive help performing living skills. Needs help keeping SSI, reapplying for Medicaid because of loss, desires sufficient skills for managing financial resources such as budgeting, or desires increased access to finances.

Rating 1: Needs monitoring to ensure support for managing financial resources, maintaining basic living skills, and household management meets the person’s needs with current services in place.

Work and School

Helpful information: 

Not applicable. If the person is too young to work, use Not Applicable

The ECC coordinator must complete the Work and School Domain in Section 2 – Assessment, specifically to determine a person’s interest in employment. 

Per Texas Administrative Code (TAC), Title 26, Part 1, Chapter 284 and instructions for Form 8401, Employment First Discovery Tool:

Ask the person about their desire to work and document their answer on this form. If the person shows a desire to work, you must complete Form 8401, Employment First Discovery Tool. Then make a referral to the Texas Workforce Commission. They may refer the person to employment services through the waiver program where the person is enrolled.

Example ratings:

Rating 3: Is losing their job and has no money to pay bills. Has reduction in school time. Needs help with crisis planning that involves job or school. Has emergency meetings at job or school. 

Rating 2: Desires help locating work or volunteer opportunity. Has change in school, is leaving school or is transition planning. The person is in their last year of high school. 

Rating 1: Has annual involvement in the admission, review, and dismissal (ARD) committee meetings or needs help developing an individualized education program (IEP).

Rating 0: The person does not attend school, have a job, or have any interest in seeking employment or volunteer work.

Relationships and Social Inclusion

Helpful information: 

Any references to community or community involvement in this domain are not about transportation. Ratings related to transportation are in the independent living domain.

Example ratings:

Rating 3: Has concerns about building healthy relationships, loss of significant relationships or conflicts with family. 

Rating 2: Desires increased participation in the community but struggles to interact with others and is unsure of social role. Has barriers to friendships. 

Rating 1: Has a good support system but may need information about community events that meet their interests.

Section 3 - Service Coordination

Section 3 has three parts: 

  • Understanding Requirements of Service Coordination
  • Determining Eligibility for Service Coordination
  • Determining Frequency for In-Person Service Coordination 

Understanding Requirements of Service Coordination

Review the rules about the requirements of service coordination in 26 TAC Sections 331.7, 331.11 and 331.5. The person may prefer more frequent in-person contact or may need it because of health or safety concerns.

Determining Eligibility for Service Coordination 

Check only one box to state if the person is eligible for service coordination based on the ratings.

There are three options to choose from: 

  • The person has two or more domains with a rating of 3, 2 or 1. 
    26 TAC Section 331.7 (a)(1)(A) states a person must have two or more documented needs. These needs require services and supports other than service coordination proven by an assessment handled by the designated LIDDA. The person does not live in an institution. Each domain with a rating of 1, 2, or 3 counts as a documented need.
  • The person meets other eligibility criteria in 26 TAC Section 331.7. 
    Review 26 TAC Section 331.7 (a)(1)(B), (C), (D), (E), or (F) to determine if the person meets other eligibility criteria.
  • The person is not eligible for service coordination if there are no domains with a rating of 3, 2 or 1. The person or their LAR may request annual contact. 
    This person is not eligible for service coordination. They are eligible to be reassessed annually or if needs change.

Determining Frequency for In-Person Service Coordination

In person or in-person, means within the physical presence of another person. In person does not include audio-visual or audio-only communication.

After you complete all the domain ratings, review the ratings with the person and their LAR. Determine the frequency of in-person service coordination based on the ratings. Consult the chart to determine high, moderate or minimal frequency for in-person contact.

Check the appropriate box about the determined frequency of service coordination. The boxes are monthly, at least twice every 90 days or at least every 90 days. The minimum frequency for in-person service coordination is at least every 90 days, or more frequently depending on each program’s requirements. 

Section 4 - Agreement 

Printed Name of Person or LAR — Enter the name of the person responsible for signing this form. 

Signature of Person or LAR — The person or their LAR signs the form. 

Date — Enter the date with month, day and year the person or LAR signed the form.

Printed Name of LIDDA Representative Completing this Assessment — Enter the name of the person that completed this assessment.

Title of LIDDA Representative Completing this Assessment — Include the job title of the person from the LIDDA completing this assessment.

Signature and Title of LIDDA Representative Completing this Assessment — The LIDDA representative that completed this assessment signs the form.

Date — Enter the date with month, day and year the LIDDA representative signed the form.