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Residential Support Services
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Elton Hills Home
Overland Home
Ridgeview Home
Sierra Home
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FAQ
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Adult IHS Application
Please provide the most information that you accurately can. This information will benefit you and your progress throughout your time with this program. Please inform the Program Director of any mistakes or changes that need to be made.
Date
*
MM
DD
YYYY
Referred by
Desired Program
*
Adult ILS
Apartment with Services
Both
Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
Email address
*
May we communicate with you via text messages?
*
Yes
No
Age
*
Gender
*
Male
Female
Living Situation
*
Independent
With Spouse/Family
Group/Foster Care
Group/Foster Home Name
Group/Foster Home Phone
Social Security Number
*
MA/Medicare Number
Guardian Information
Guardian Name
Guardian Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Guardian Phone
Alternate Phone
Emergency Contact Information
Emergency Contact Name
*
Relationship to Applicant
*
Emergency Contact Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact Phone
*
Emergency Contact Alternate Phone
*
Emergency Contact 2 Information
Emergency Contact 2 Name
Relationship to Applicant
Emergency Contact 2 Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact 2 Phone
Emergency Contact 2 Alternate Phone
Social Worker Information
Social Worker Name
*
County
*
Social Worker Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Social Worker Phone
*
Social Worker Email
*
Funding
*
CADI
TBI
DD
Private Pay
Family Information
Marital Status
*
Single
Married
Divorced
Widowed
Spouse Name
Spouse Phone
Religious Preference
Do you have a living will
*
Yes
No
Do Not Resuscitate Order
*
Yes
No
Doctor Information
Physician Name
*
Clinic
*
Clinic Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Physician Phone
*
Clinic Phone
(if different from Physician phone)
Health Information
Diagnosis
*
Date of last visit
*
MM
DD
YYYY
Reason
*
Date of last Mantoux test or chest x-ray
*
MM
DD
YYYY
Allergies
*
Hearing
*
Good
Impaired
Hearing Aids
Deaf
Vision
*
Good
Impaired
Glasses
Blind
Ambulation
*
Self
Cane/walker
Wheelchair
Other
Toileting
*
Self
Needs Assistance
Wears Protective Garment
Personal Hygiene
*
Self
Needs Assistance
Other
Self Preservation
*
Yes
No
Medical Conditions
*
Medications
*
Diet Restrictions
*
Diabetic
*
Yes
No
Insulin Dependent
*
Yes
No
Current Transportation
*
Would you be interested in using our transportation services?
*
Section 9
Signature
*
By entering my name below, I verify that all of the information provided is correct to the best of my knowledge.
First Name
Last Name
Thank you!
