• Resident Application

    Applicant & Contacts
  • Todays Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Sex

  • Current & Previous Living Settings

  • Current living situation*
  • Ever lived in BI supportive living, assisted living, or nursing facility?*
  • Currently Employed
  • Do you drive?
  • Do you drink alcohol?

  • Brain Injury & Rehabilitation

  • Date of Brain Injury
     - -
    2 digit month, 2 digit day, 4 digit year

  • Health, Diabetes & Medication Support

  • Do you issues with your vision?
  • Do you need or wear glasses?
  • Do you have issues with your hearing?
  • Do you need or wear hearing aids?
  • Do you use oxygen?
  • Do you have seizures? Do you take medications to control ?
  • Does the applicant have diabetes?*
  • How is diabetes managed?
  • Can applicant prepare and administer required injections independently?
  • Do you have eating or swallowing concerns?
  • Do you have issues with your speech?
  • Do you have pain?
  • Do you have issues controlling your bladder?
  • Do you have issues controlling your bowels?
  • Do you have dietary restrictions or allergies?

  • Medications

  • Does applicant currently take medications?*
  • Medication support level*
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  • Daily Living, Mobility, Cognition & Safety

  • Daily living assistance*
    Rows
  • Is continence care needed?*

  • Mobility

  • Mobility aids*
  • Transfer assistance*
    Rows
  • Can you go up and down stairs independently?
  • Falls in past six months?*

  • Cognition

  • Cognitive support needs*
    Rows
  • History of getting lost, unsafe exits or need for secured setting?*

  • Mental & Behavioral Health; Daily Life

  • Do you have any problems with the following?
    Rows
  • Diagnosed mental or behavioral health conditions*
  • Current behavioral concerns*
  • Do you have problems with frustration?
  • Currently receiving behavioral health treatment and/or counseling?*
  • Do you have problems with thoughts of suicide?
  • Do you have problems with anger?
  • When you get angry, do you do the following?
    Rows
  • Does the resident need assistance arranging transportation to medical appointments?*
  • Does the resident require assistance with scheduling medical, dental, or other healthcare appointments?*

  • Background & Funding

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  • Ever convicted of a criminal offense?*
  • Pending charges or court-related restrictions?*
  • Current recreational substance use*
  • Do you manage your money?
  • Past treatment for alcohol or substance use?*
  • Do you have insurance?
  • Cigarette/vaping use*
  • Coverage*
  • Do you have Medicaid?
  • Do you have Medicare?
  • Medicaid Long-term Care HCBS Brain Injury waiver status*
  • Sources of income for room and board*
  • If no current income, has the applicant applied for SSI or SSDI?*

  • Records & Attestation

  • Role of legal representative
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  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Duplicate - not used
  • Duplicate widget - not used
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