Resident Application
Todays Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number
Sex
Male
Female
Other
Currently Employed
Yes
No
Current Employer
Highest level of education completed?
Do you drive?
Yes
No
Do you smoke?
Yes
No
Do you drink alcohol?
Yes
No
History of Substance Abuse (Alcohol and/or Drugs)?
Yes
No
History of Substance Abuse Details
Have you been arrested?
Yes
No
Arrest History Details include charges and convictions
Brain Injury Information
Diagnosis Code if Known
Date of Brain Injury
-
Month
-
Day
Year
Date
How was the brain injury acquired?
How long in a coma?
Where did you attend rehab and how long were you in rehab?
Medical Information
Do you issues with your vision?
Yes
No
If Yes please describe the issues with your vision?
Do you need or wear glasses?
Yes
No
Do you have issues with your hearing?
Yes
No
If Yes please describe the issues with your hearing?
Do you need or wear hearing aids?
Yes
No
Do you use oxygen?
Yes
No
If Yes to use oxygen how often?
Do you have seizures? Do you take medications to control ?
Yes
No
If Yes what medication do you take for seizures?
What was the date of your last seizure?
Do you have diabetes?
Yes
No
If Yes what medication do you take for for diabetes?
Do you have eating or swallowing concerns?
Yes
No
If Yes please provide details on swallowing concerns
Do you have issues with your speech?
Yes
No
If Yes please provide details on issues with your speech
Do you have pain?
Yes
No
If yes please describe the pain and where it is?
Do you have issues controlling your bladder?
Yes
No
If yes, how often and what incontinence supplies or equipment do you use for bladder support?
Do you have issues controlling your bowels?
Yes
No
If yes, how often and what incontinence supplies or equipment do you use for bowel support?
Do you have dietary restrictions or allergies?
Yes
No
If yes please explain any dietary restrictions or allergies
Upload a copy of the most recent history and physical (H&P) from your physician
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Medications
Do you require assistance with medications?
Yes
No
Do you have any medication allergies? if so, please list them here.
Please upload a list of medications
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Activities of Daily Living Skills
Check level of assistance required for each task
Independent
Cues or Supervision
Full Assistance
Bathing
Toileting
Dressing
Brushing Teeth or Cleaning Dentures
Brushing and/or styling hair
Shaving
Feeding self
Cooking
Laundry
Cleaning room/home
Reading
Writing
Using Telephone
Mobility
Do you use any of the following?
Wheelcair
Walker
Cane
Other
Can you go up and down stairs independently?
Yes
No
Do you have balance issues?
Yes
No
If yes please describe balance issues and date of last fall
Do you need help with the following?
Yes
No
Getting in and out of bed
Getting in and out of the shower
Getting on and off the toilet
Getting in and out of a chair
Cognition
Do you have problems with the following cognition issues?
Yes
No
Memory
Orientation to time, person or place
Confusion
Initiating activities
Planning
Organization
Judgment
Do you have any other cognition issues? Please describe.
Mental Health and Behaviors
Do you have any problems with the following?
Yes
No
Depression
Anxiety
Bi-polar
Schizophrenia
Eating Disorders
Obsessive Compulsive disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Autism
Attention Deficit Hyperactivity Disorder (ADHD)
Addictive Behaviors
Do you have problems with frustration?
Yes
No
If yes to frustration, please explain what causes frustration and describe coping strategies you use to deal with the frustration.
Do you have problems with thoughts of suicide?
Yes
No
If yes to suicide please provide details
Do you have problems with anger?
Yes
No
If yes to anger please explain what causes anger and how you calm down
When you get angry, do you do the following?
Yes
no
Swear at others
Threaten others
Hit or become physical with others
Throw or break things
Do nothing
Walk away
Please upload copy of document designating guardian, conservator, power of attorney.
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Do you manage your money?
Yes
No
If no, who manages your money?
Do you have insurance?
Yes
No
If yes to insurance what is the company, policy and ID#?
Do you have Medicaid?
Yes
No
What is your Medicaid ID#?
Do you have Medicare?
Yes
No
What is your Medicare ID#?
Do you have Home and Community Based Services (HCBS)? Brain Injury Waiver?
Yes
No
If yes to HCBS, which waiver?
What is the name, phone and or email of your county case manager?
What are your sources of income (select all that apply)
Social Security Disability-SSDI
Supplemental Social Security – SSI
Other
What is your monthly income?
Responsible Party Information
Name of person completing application
Relationship to applicant
Name of legal representative
Role of legal representative
Guardian
Power of Attorney
Other
Legal Representative Phone Number
Please enter a valid phone number.
Legal Representative Email
example@example.com
Date of Signature
-
Month
-
Day
Year
Date
By signing this application, I give Flourish permission to reach out to my medical providers, other service providers and case managers to obtain financial and medical information including mental healthcare, communicable diseases including HIV/AIDS and treatment of alcohol and/or drug abuse needed for admission to Flourish Supportive Living. I also authorize Flourish to run a criminal background check. Signature of patient or personal representative.
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