Resident Application

Todays Date

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.

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

Diagnosis Code if Known

Date of Brain Injury

Date

How was the brain injury acquired?

How long in a coma?

Where did you attend rehab and how long were you in rehab?

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 how oxygen do you require and 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? Do you take medications for diabetes?

Yes No

If Yes what medication do you take for for diabetes?

Do you have eating or swallowing concerns?

Yes No

Do you have issues with your speech?

Yes No

Do you have pain?

Yes No

If yes please describe the pain and where it is?

Do you have issues controlling your bladder or bowels?

Yes No

If yes please explain any bladder or bowel issues

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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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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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

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

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.

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

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

Name of person completing application

Relationship to applicant

Name of legal representative

Role of legal representative

Guardian Power of Attorney Other

Phone Number

Please enter a valid phone number.

Email

example@example.com

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)?

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?

Social Security Number

Date of Signature

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. *

Clear

Resident Application

Brain Injury Information

Medical Information

Medications

Activities of Daily Living Skills

Mobility

Cognition

Mental Health and Behaviors

Responsible Party Information