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California SOC 821 IHSS Protective Supervision Form

IHSS Protective Supervision pays for someone to watch a non-self-directing, confused or mentally impaired person to prevent accidents. Before the county decides, the IHSS social worker sends this form to the treating physician or medical professional, who gives the diagnosis and prognosis, rates memory, orientation and judgment, and reports injuries caused by those deficits and whether the person can still physically put themselves in danger.

Who completes it

The attending physician or another licensed medical professional, such as a psychiatrist or psychologist, completes everything below the county's header and signs with specialty and license number. The county fills in the patient and social worker details and attaches a release of information.

Submitting and payment

How to submit it
Return the form promptly to the county IHSS social worker at the address shown at the bottom of page 2.
Who pays
The form sets no fee and does not say who pays for completing it.

Good to know

  • Protective Supervision does not apply when the need stems from a physical rather than mental condition, for social visits, for medical supervision, in anticipation of a medical emergency, or to control aggressive behavior.
  • Memory and orientation are rated no deficit, moderate or severe, and judgment unimpaired, mildly or severely impaired; any impaired rating needs an explanation.
  • The form asks whether the person retains the mobility or physical capacity to place themselves in a hazardous situation, alongside any injuries already caused by their deficits.
  • The county social worker makes the decision; a related form, SOC 825, documents the 24-hours-a-day coverage plan.

Get the official form

Download the current version from the source each time; forms change without notice.

Assessment of Need for Protective Supervision for In-Home Supportive Services Program

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Who can complete the SOC 821?

The patient's attending physician or another medical professional licensed to practice in California, such as a psychiatrist or psychologist. The signer certifies their licensure and gives their medical specialty, license number and the date, along with how long they have treated the patient and when they last saw them.

When is IHSS Protective Supervision not available?

The form lists five situations: the need is caused by a physical condition rather than a mental impairment, it is for friendly visiting or social activities, the supervision needed is medical, it is in anticipation of a medical emergency such as seizures, or it is to prevent or control antisocial or aggressive behavior.

Does the SOC 821 decide Protective Supervision?

No. The county IHSS social worker decides eligibility using this assessment along with the rest of the IHSS case. The form cites Welfare and Institutions Code section 12301.21 and asks the clinician to complete and return it promptly.