Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Gender

Male

Female

Other

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Marital Status

Married

Divorced

Widowed

Single

Spouse's Name

First Name

Last Name

Spouse's Phone

(###)

###

####

Living Situation *

Independent

Family

Group/Foster Home

Other

Is individual their own Guardian?

Yes

No

If "No," Guardian name

First Name

Last Name

Guardian Phone

(###)

###

####

Case Manager Name

First Name

Last Name

Case Manager Phone

(###)

###

####

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

(###)

###

####

CADI Waiver

Approved

Possible

BI Waiver

Approved

Possible

Elderly

Approved

Possible

Private Pay

Approved

Possible

Physical and Mental Health Needs

Mobility (uses wheelchair, walker or has unsteady gait)

Assistance with taking medications

Special Diet

Oversight by Mental Health Practitioner

Health and Medical (serious medical conditions)

Speech

Hearing

Sight

Other

Accessibility Needs

Wheelchair Accessible

One Level/No Stairs

No Restrictions

Other

Activities of Daily Living (ADLs) Support Needs

Dressing

Bathing/Hygiene

Toileting

Money Management

Self-Preservation

Mobility

Eating

Transferring

Medical Appointments

Other

Physician Name

First Name

Last Name

Physician Phone

(###)

###

####

Pre-Diabetic?

Yes

No

Diabetic?

Yes

No

Insulin Dependant?

Yes

No

Hearing

Good

Impaired

Hearing Aids

Deaf

Vision

Good

Impaired

Glasses

Blind

Date of last Mantoux test or chest X-Ray

(must be within last 3 months)

MM

DD

YYYY

Behavioral Support Needs

Current or History of aggressive physical behavior towards others

Current or History of aggressive physical behavior toward self

Current or History of aggressive verbal behavior toward others

Current or History of property destruction

Current or History of refusing essential care (diet, medications, personal care)

Substance Use (cigarettes, alcohol, drugs, etc.)

Impairments of judgement, ability to recognize reality, or ability to cope with ordinary life demands

Other

Education/Employment Support Needs

Interested in assistance with finding educational support

Interested in assistance with finding vocational or employment support

Other

Legal Restrictions

Guardian

Conservator

Representative Payee

Court Committed

Power of Attorney

Felony Convictions

Other

Individual Completing Application

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Date Completed

MM

DD

YYYY