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Pre Admission Screening
Pre Admission Form
Full Name
*
Other Names You Go by or Went
Email
*
Phone
*
Date of Birth
*
Language
*
English
Spanish
Bilingual
Other
Previous Address With City and State
Emergency Contact Names, Phone Numbers, Relationship
US Citizen
*
Yes
No
Documentation You Already Have In Your Possession (check all that apply)
*
State Picture ID
Social Security Card
Birth Certificate
Pay Stubs
Benefit Letter from Social Security
Debit or Bank Card
Food Card (ex.:SNAP, UHC, Health Benefit Card etc...)
None
Marital Status
*
Marital Status
Divorce
Widowed
Single
Allergies- NA for None
*
Height
*
Weight
*
Pregnant
*
Yes
No
Maybe
Medical Conditions- NA for none
*
Medications (Prescribed/OTC)- NA for none
*
Do You Understand That Taking Your Medications On Time Is Important? Do You Agree To Medication Monitoring?
*
Yes
No
Are You Currently Employed
*
Yes
No
Principle Source of Income
*
SSI/SSDI
Private Pay
Employed
VA Benefits
SNAP
Rental Assistance/Voucher
Pension
Other
Guaranteed Monthly Income Amount-- Will be Required to provide Proof of Income(Example: SSI Benefit Letter, Bank Statement, 2 Check Stubs)
*
Health Insurance
*
Medicaid
Medicare
Humana
Private Insurance
None
Other
Pets/Service Animals
*
Yes
No
Smoker
*
Yes
No
Maybe
Veteran
*
Yes
No
Do you give Consent for our Company to Review Your History and Physical (H&P)
*
Yes
No
Substance Abuse or Recreational Drug Use
*
Yes
No
Maybe
Current Probation/Parole
*
Yes
No
Pending Cases
*
Yes
No
Criminal History - Do you agree to a Background Check
*
Yes
No
SSN
*
How would rate your current health status (5 being excellent health, 1 being poor health)
Do you use Assisted Devices
*
Glasses
Dentures
Cane
Walker
Wheelchair
Rollator
Prosthesis
Urinary Catheter
Colostomy
Oxygen
Cpap/Bipap
Hearing aids
None
Other
Addictions
*
Yes
No
Maybe
Victim of Trauma/Abuse
*
Yes
No
Maybe
Require Special Accommodations(Ex. Medication Reminders/Administration, Transfer Assist, Mobility Assist)
*
Yes
No
Maybe
Require Assist with Personal Care (Bathing, Toileting, Dressing, Mobility and Transferring, Meal Prep, Housekeeping)
*
Yes
No
Maybe
Are You Able to Prepare Own Meals
*
Yes
No
Already receiving assistance with Personal Care
*
Yes
No
Maybe
Are You Able to Budget and Grocery Shop
*
Yes
No
Maybe
Have Transportation (Medical or Personal)
*
Yes
No
Maybe
Support from Family or Friend
*
Yes
No
Maybe
Name of any Persons that is NOT to Make Contact with you- NA if not applicable
*
Move in Date
How did you hear about us?\
Social Worker/Case Worker
Zillow/Hotpad
Facebook/Craigslist/Instagram/Social Media
Family Member/Friend
Other
Are You Aware that Our Program is SHARED HOUSING and that you may be being sharing a room with a roommate of your same sex(gender)?
*
Yes
No
Additional Comments or Why do you think you would be a Good Fit
*
Submit
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