WPC= i䍯'3:7UϮq06K5b2 ` `o#Og5LUïV(MK$IV`99)v|qdޫmhy]?SZ{3Df-#~]ŒB  q-N>&MJU ~%4/gj\jrjtˏӃ{̜JV:Ĝ2(q{hf,s5?q39Z`=~@DZ*Iq.  o)X&r\.(_[&?J%zkvd#CLC#l꜑y&kc,! ,H?G| s: ņ-Vtz(ђ=к?TMYMJ5e$]5i ^!s%δrh %-pڱbc#b UN+ %y 0: g 0V wv4zm 0VQ`^ b mnU 0fa 0U 0  0 0 0 0@ 0 0 0G 0 0 0~ 01 0 0 0& 0 0V 0 0 0s 0# 0 0q 0! 0! 09" 0" 0u# 03$ 0>$ 0/% 0'& 0 ' 0' 0( 0) 0* 0K+ 02, 0O, 0:K- 0Y- 0_- 0 =. 0G/ 00 D/2 D+2 0)3 D//5 0^5 06,6 0b6 0:j7 0^7 0<8 1e>8U68U>8U*9 1uA9 729N9f9a9 B5:~5:5:5:f<a<< 0c<<<< B,=,=,=,=,=,=,=,=,=,=,=,=,=,=,=,=,=,=,=,=,= BI=I=I= B*f=f=f=f=f=f=f=f=f=f=f=f=f=f=f= BE-=HP PSC 1600 seriesTT0(9 Z6Times New Roman RegularX($USUS., ] 'USUS.,  _(#X$XXWVHome&CommunityBased**7(#VERSIONMRUWVDRAFTԈ X ServicesWaiverApplication_MR_/DDWaiver#X,X$X#(.3$ !USUS.,  S2:i+00 c  )USUS.,  _$XX (#X STATE :WestVirginia9(#DATE:July1,2005 X Attachment3:Page1  }d$Reference:DD3PsychologicalEvaluation#$}d#(.3$ !USUS.,  3|xr2 U3H $AZVerdana TABLE A*+ (_2623  ..*G+G (_25   /%` ` hp x /23  ../%` ` hp x /   *8+8 (_24  ," hp x ,23  ..," hp x ,  *5+5 (_23 ` ) hp x )23  ..) hp x ) ` *2+2 (_22  &hhp x &23  ..&hhp x &  */+/ (_21  #p x #23  ..#p x #  *,+, (_20 h  p x 23  .. p x h *)+) (_19  pp x 23  ..pp x   *&+& (_18   x 23  .. x   *AA (_17  5+ ` hp x 523  Ԁ5+ ` hp x 5  *GG (_16   /%` ` hp x /23  Ԁ/%` ` hp x /   *88 (_15  ," hp x ,23  Ԁ," hp x ,  *55 (_14 ` ) hp x )23  Ԁ) hp x ) ` *22 (_13  &hhp x &23  Ԁ&hhp x &  *// (_12  #p x #23  Ԁ#p x #  *,, (_11 h  p x 23  Ԁ p x h *)) (_10  pp x 23  Ԁpp x   (&& &_9   x 23  Ԁ x   (AA &_8  5+ ` hp x 523  5+ ` hp x 5  (GG &_7   /%` ` hp x /23  /%` ` hp x /   (88 &_6  ," hp x ,23  ," hp x ,  (55 &_5 ` ) hp x )23  ) hp x ) ` (22 &_4  &hhp x &23  &hhp x &  (// &_3  #p x #23  #p x #  (,, &_2 h  p x 23   p x h ()) &_1  pp x 23  pp x   &&& $_   x 23   x   0AA.Normal  5+ ` hp x 55+ ` hp x 5  <AA:Definition T  5+ ` hp x 55+ ` hp x 5  <AA:Definition L , 5+ ` hp x 5  5+ ` hp x 586Definition(hh&H1  5+ ` hp x 5      5+ ` hp x 5  (]]&H2  5+ ` hp x 5  5+ ` hp x 5  (]]&H3  5+ ` hp x 5  5+ ` hp x 5  (]]&H4  5+ ` hp x 5 XXX 5+ ` hp x 5  (]]&H5  5+ ` hp x 5  5+ ` hp x 5  (]]&H6  5+ ` hp x 5  5+ ` hp x 5  2DD0Address  5+ ` hp x 55+ ` hp x 5  8MM6Blockquote , , 5+ ` hp x 5   5+ ` hp x 5,*CITE,dl*CODEKL<6X9`(Courier NewKSM\  `&Times New RomanS42Emphasis64Hyperlink    <:FollowedHype    4go2Keyboard KL<6X9`(Courier NewKSM\  `&Times New RomanS <:Preformatted  /%  ,Kk %#/KL<6X9`(Courier NewKSM\  `&Times New RomanS/%  ,Kk %#/  <:zBottom of 7A(X7    5+ ` hp x 5?N%2A`Arial?  SM\  `&Times New RomanS7B(X75+ ` hp x 5  w)1dxd'dxd<:zTop of For7D(X7    5+ ` hp x 5?N%2A`Arial?  SM\  `&Times New RomanS7B(X75+ ` hp x 5  w)2dxd0KS.SampleKL<6X9`(Courier NewKSM\  `&Times New RomanS0.Strong 8dl6TypewriterKL<6X9`(Courier NewKSM\  `&Times New RomanS42Variable: 8HTML MarkupB      2 0CommentB   !" 35;AGMSY_11.1.1.1.1.1.1.1.<6X9`(Courier New\  `&Times New Roman%2A`Arial3#37=CIQYag1.a.i.(1)(a)(i)1)a)Oi)TABLE B1Large Dashed dDD-3 (proposed)   ' MRU WV0Debi .   TABLE D(;3$2#  0  .3  0   d d&0 d d)Hairline d !USUS.,  _XX   __xX4XXXe^XX4WESTVIRGINIADEPARTMENTOFHEALTHANDHUMANRESOURCES X PSYCHOLOGICALEVALUATION   Tge^  *ddd Xdd Xdd X(#(#, , , , +  /% /ParticipantName: =,! = 6,!" 6Date: .3 . G='"   GParticipantAddress: =,!x = 6,!x" 6_Birthdate_: .x 3 . G='x "   G =,!H  = 6,!H " 6SS#: .H 3 . G='H"   G =,!p = 6,!p" 6Medicaid#: .p3 . G='p"   GParticipanteMail: =,!@  = 6,!@ " 6Phone: .@ 3 . PF'@ "   <P OE/ " <  OBehavioralHealthCenter: =,!L  = 6,!L " 6 'L 3 ' 8.L   8_BHC_ԀAddress: =,!  = 6,! " 6Phone: . 3 . G=' "   G =,!   = 6,! !" 6Fax: . "3 . PF' #"   <P OE/ L$" <  OLicensedPsychologist: =,! % = 6,! &" 6 ' '3 ' 8. (  8PsychologistAddress: =,! p ) = 6,! p *" 6Phone: . p +3 . G=' p ,"   G =,!@ - = 6,!@ ." 6Fax: .@ /3 .7-+@ 0"   7*XYd d    (#(#_,X , ,P +  0& 1   0DIAGNOSES(DSMIV) 6% 2    6  :0!t 3  :ЀAxisI:ClinicalDisorders,,TgԀ(includesallthementalhealthconditionsnotcoveredbyAxisII)#Tg,,@# ;1t 4    ;  A0!8 5  A  J@*8 6    J  A0!T 7  A  E4*T 8    E  :0!9  :ЀAxisII:PersonalityDisordersandMentalRetardation ;1:    ;  A0!;  A  J@*<    J  A0!H=  A  E4*H>    E  :0!d ?  :ЀAxisIII:GeneralMedicalCondition,,TgԀ(majormedicalconditionsthatmayberelevanttotreatmentofthementalhealthdisorder)#Tg,,# ;1d @    ;  A0!(A  A  J@*(B    J  A0!C  A  E4*D    E  :0!XE  :ЀAxisIV:_Psychosocial_ԀandEnvironmentalFactors ;1XF    ;  A0!tG  A  J@*tH    J  A0!8I  A  E4*8J    E  :0!K  :ЀAxisV:GlobalAssessmentofFunctioning ;1L    ;  A0!hM  A  J@*hN    J  A0!,O  A  PF*,P   <P  A7 0Q  <   ASUBSTANTIALADAPTIVEDEFICITS(Attachreports/assessmentsasappropriate) D3,R    D 6,!HS" 6ЀSELFCARE .HT . UD,HU     U 6,! V" 6ЀCOMMUNICATION . W . UD, X     U 6,!xY" 6RECEPTIVELANGUAGE .xZ3 . UD,x[     U 6,!<\" 6EXPRESSIVELANGUAGE .<]3 . UD,<^     U 6,!X _" 6ЀLEARNING .X ` . UD,X a     U 6,!!b" 6  FUNCTIONALACADEMICS .!c0 . UD,!d     U 6,!!e" 6  ӀMOBILITY .!f . UD,!g     U 6,!"Lh" 6  ӀSELFDIRECTION ."Li . UD,"Lj     U 6,!h#k" 6  ӀINDEPENDENTLIVING .h#l . UD,h#m     U 6,!,$n" 6HOMELIVING .,$o3 . UD,,$p     U 6,!$ q" 6SOCIALSKILLS .$ r3 . UD,$ s     U 6,!%\!t" 6EMPLOYMENT .%\!u3 . UD,%\!v     U 6,!x& "w" 6HEALTH&SAFETY .x& "x3 . UD,x& "y     U 6,!<'"z" 6COMMUNITYUSE .<'"{3 . P?,<'"|     P 6,!(#}" 6  LEISURE .(#~0 .7-+(#   7  e^TgIcertifythatthisindividualsdiagnosesandadaptivedeficitsareasdocumentedabove,andthe L)$ individual,butfortheprovisionofhomeandcommunitybasedwaiverservices,wouldrequire *% thelevelofcareprovidedinanintermediatecarefacilityforthementallyretarded(_ICF_/_MR_).#Tge^x'# *& *RSd!dX X P PXY(#(#, , , +  8'D,'D,' 8 =,!D,'" = =,!D,'" = ND,D,'"   NDate ',(" 'SignatureofLicensedPsychologist ',(" 'License#-#!,("   -