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Cart
0
About
What We Do
Our Story
Our Staff
Contact
Programs
Adult Day Program
Apartments With Services
Independent Living Skills
Residential Support Services
Respite Services
Youth Skill Building Program
Housing
Housing Openings
56th St. Apartments
75th St. Apartments
Lincoln Home
Overland Home
Ridgeview
Timberwood Home
Villa Haven
Villa Home
FAQ
Careers
Residential Support Services Application
Date
*
Date
MM
DD
YYYY
Name
*
Name
First Name
Last Name
Gender
*
Male
Female
Age
*
Diagnosis
*
Addiction
*
Years sober
Criminal Record
*
Guardian
*
Social Worker
*
History
Where are you currently living?
*
How long have you lived there?
*
What do you like about your current living situation?
*
What do you dislike about your current living situation?
*
What was your former housing situation?
*
Tell us a little bit about your work history.
*
What are your interests?
*
Do you have any hobbies?
What is important to you?
Relationships
Marital Status
*
Single
Married
Divorced
Widowed
Do you have any children
*
Yes
No
If yes, what are their ages?
Do you have strong family relationships?
*
Yes
No
Do you have long term friends?
*
Yes
No
Do you have limited contact with others?
*
Yes
No
Do you prefer to be alone?
*
Yes
No
Are you a social person?
*
Yes
No
Additional notes
Health
Do you take your medication accurately?
*
Yes
No
Are you diabetic?
*
Yes
No
Do you follow a specific diet?
*
Yes
No
If yes, please describe
Are you able to complete your own personal cares
*
Yes
No
Are you able to dress independently?
*
Yes
No
Are you able to toilet independently?
*
Yes
No
Do you need prompts for hygiene cares?
*
Yes
No
Do you adhere to doctor's orders?
*
Yes
No
Are you able to transfer independently?
*
Yes
No
Do you have allergies?
*
Yes
No
If yes, to what?
Additional Notes
Behavior
Are you even-tempered under pressure?
*
Yes
No
Do you set high standards for yourself?
*
Yes
No
Do you get frustrated easily?
*
Yes
No
Are you verbally abusive to others?
*
Yes
No
Are you physically abusive to others?
*
Yes
No
Do you have a history of physical violence?
*
Yes
No
What are some of your triggers?
*
Additional Notes
Communication
Are you able to process received information?
*
Yes
No
Do you listen to others?
*
Yes
No
Are your thoughts organized?
*
Yes
No
Do you feel you communicate effectively?
*
Yes
No
Do you prefer verbal communication?
*
Yes
No
Do you prefer written communication?
*
Yes
No
Additional Notes
Life Management
Are you organized?
*
Yes
No
Do you use structure in your life?
*
Yes
No
Do you adhere to a schedule?
*
Yes
No
Are you able to schedule appointments?
*
Yes
No
Do you attend doctor appointments independently?
*
Yes
No
Do you need assistance with transportation?
*
Yes
No
Can you shop for personal needs independently?
*
Yes
No
Are you a morning person?
*
Yes
No
Are you responsible for your finances?
*
Yes
No
Additional Notes
Personal Growth
Do you have goals?
*
Yes
No
Are you motivated to achieve your goals?
*
Yes
No
Additional Notes
Other
Do you mind living with males and females?
*
Yes
No
Do you mind who does your cares?
*
Yes
No
If yes, please list your preferences
Do you have any pets?
*
Yes
No
If yes, how many and what kind?
Do you need bedroom furniture?
*
Yes
No
If yes, what furniture do you need?
Additional Notes
Is there anything else you would like to share?
Section 9
How did you hear about SMB Disability Solutions?
*
Indeed
Facebook
Website
Advertisement
SMB Employee
Other
Other
Thank you!