• Lifestyle Session Application

    Lifestyle Session Application

  • If you are accepted for a session, you will receive a {sessionDiscount}% discount. 🎉

  • Submission Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Are you the session participant for this application?*
  • Format: (000) 000-00[0][0][0][0][0][0].

  • Participant's Personal Information

  • Do you have any other names that you have gone by in the past?*
  • Please list any other names you have gone by in the past (maiden name, last name from a previous marriage, etc.)*
  • Format: (000) 000-00[0][0][0][0][0][0].
  • Format: (000) 000-00[0][0][0][0][0][0].

  • Gender*
  • Date of Birth*
     / /
  • How did you hear about Uchee Pines? Select all that apply.*
  • Please select your status*
  • Did your physician refer you to the program?*
  • Have you previously seen or talked to a healthcare provider at Uchee Pines?*
  • Is there a companion who will be going through the program with you?*
  • Emergency Contact *
  • *Do not change unless absolutely necessary* Which session do you want to attend? (first day of the session) *
     - -
    2 digit month, 2 digit day, 4 digit year
  • Last day of the session
     - -
    2 digit month, 2 digit day, 4 digit year
  • Select your preferred session dates for the Lifestyle Program you wish to attend.*
  • How do you plan to travel to Uchee Pines?*

  • Participant's Physical Condition

  • List ALL problems/diagnoses along with other information required.*
  • What is your level of functioning now?*
  • Do you need help with personal care - dressing, bathing, feeding, walking?*
  • Can you get into and out of bed on your own?*
  • Are you strong enough to get into a high bathtub? (20 inches)*
  • Do you have any problems with eating or your appetite?*
  • Do you take any medications or supplements?
  • List ALL medications and supplements along with other information required.*
  • Do you drink alcohol?
  • If so, what type, how often, and how much?*
  • Do you smoke?
  • If so, how often and how much?*

  • Participant's Mental and Emotional Histories

  • Do you have any mental or emotional challenges? *
  • Please select all that apply.*
  • Do you have any behavioral/anger outbursts?*
  • Have you been seen by a psychiatrist?*
  • Are you on or have been on medication(s)? If so, which one(s)? What were (are) the effects on you?*

  • Companion's Personal Information

    This portion is specifically for your companion. Please fill it out accordingly.
  • Format: (000) 000-00[0][0][0][0][0][0].

  • Gender*
  • Date of Birth*
     / /
  • How did you hear about Uchee Pines? Select all that apply.*
  • Please select your status*
  • Did a physician refer your companion to the program?*
  • Have you previously seen or talked to a healthcare provider at Uchee Pines?*
  • Select your preferred session dates for the Lifestyle Program you wish to attend.*

  • Companion's Physical Condition

  • List ALL problems/diagnoses along with other information required.*
  • What is your level of functioning now?*
  • Do you need help with personal care - dressing, bathing, feeding, walking?*
  • Can you get into and out of bed on your own?*
  • Are you strong enough to get into a high bathtub? (20inches)*
  • Do you have any problems with eating or your appetite?*
  • Do you take any medications or supplements?
  • List ALL medications and supplements along with other information required.*
  • Do you drink alcohol?
  • If so, what type, how often, and how much?*
  • Do you smoke?
  • If so, how often and how much?*

  • Companion's Mental and Emotional Histories

  • Do you have any mental or emotional challenges? *
  • Please select all that apply.*
  • Do you have any behavioral/anger outbursts?*
  • Have you been seen by a psychiatrist?*
  • Should be Empty: