Name
First Name
Middle Initial
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
Township
Directions (optional)
Phone Number
Please enter a valid phone number.
What is your monthly income?
Do you live alone?
Yes
No
Household size for participant?
Two people in the household
Three people in the household
Four or more people in the household
Unknown
Marital Status
Married
Divorced
Widowed
Separated
Single
If married, what is your spouse's name?
Participant Gender(assigned at birth)
Female
Male
Other
Prefer not to disclose
No response/Unknown
Race (check all that apply)
White
Black
Asian
Native Hawaiian/Other Pacific Islander
American Indian/Native Alaskan
Is the participant multiracial?
Yes
No
Is the participant Hispanic?
Yes
No
Is the participant non-English speaking?
Yes
No
How well does the participant speak English?
Very well
Well
Not well
Not at all
Unknown
Has the participant ever served on active duty in the U.S. Armed Forces, Reserves, or National Guard?
Yes
No
Unknown
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Does the participant already have services in place with any of these agencies? (check all that apply)
MDHHS (Michigan Department of Health and Human Services)
Skilled Nursing
UPCAP Case Management
Other
If other, please explain here:
What service(s) are being requested?
Home Delivered Meals
Home Care Assistant
Homemaker Services
Respite Care
Adult Day Care
Home Injury Control
How frequently would the participant like the service(s) being requested?
If HDM was requested, what dietary restrictions are there and how frequently would the participant like meals?
Are there any food allergies to be aware of?
Are there any medical devices in your home which rely on electricity?
Yes
No
Does the participant have any pets?
Yes
No
Do you prepare nutritious meals?
Yes
Yes, with help, and assistance will continue
No
Are you able to do your routine housework?
Yes
Yes, with help, and assistance will continue
No
Can you leave your home by yourself?
Yes
Yes, with help, and assistance will continue
No
Is there someone to help you if you need it?
Yes
Yes, with help, and assistance will continue
No
Are you able to dress & undress yourself?
Yes
Yes, with help, and assistance will continue
No
Are you able to bathe yourself?
Yes
Yes, with help, and assistance will continue
No
Please verify that you are human
*
Submit
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