Lifestyle Session Application
Submission Date
*
/
Month
/
Day
Year
Are you the session participant for this application?
*
Yes
No
Name of the person filling out this application.
*
First Name
Last Name
Phone Number of the person filling out this application.
*
Participant's Personal Information
Participant's Legal Name
*
__
Mr.
Mrs.
Ms.
Miss
Prefix
First Name
Middle Name
Last Name
Do you have any other names that you have gone by in the past?
*
Yes
No
Please list any other names you have gone by in the past (maiden name, last name from a previous marriage, etc.)
*
Main Phone Number
*
Other Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Email
*
Confirmation Email
MyEmail@example.com
Gender
*
Male
Female
Date of Birth
*
/
Month
/
Day
4-digit Year ex: 1970
Date Picker Icon
Age
*
Occupation
*
(If retired, include former occupation. Example: Retired Teacher)
Church Affiliation
*
How did you hear about Uchee Pines? Select all that apply.
*
A Friend
YouTube
Church
Other Social Media
Facebook
A Brochure, Poster, etc.
Twitter
A Live Stream, Zoom-type meeting, etc.
Email from Uchee Pines
I attended a previous Uchee Pines Conference/Seminar
Browsing Uchee Pines Website
Other
Please select your status
*
Level 1 / Medical Guest
Level 2/ Non-Medical Guest
Did your physician refer you to the program?
*
Yes
No
Physician's Name
*
First Name
Last Name
Physician's Contact Information
*
Have you previously seen or talked to a healthcare provider at Uchee Pines?
*
Yes
No
Is there a companion who will be going through the program with you?
*
Yes
No
Emergency Contact
*
Select your preferred session dates for the Lifestyle Program you wish to attend.
*
Back
Next
Save
Participant's Physical Condition
Height
*
Examples: 5'2"
Weight
*
Example: 120 lbs
List ALL problems/diagnoses along with other information required.
*
How is your physical condition affecting you?
*
What is your level of functioning now?
*
Normal
Weak but can do everything
Cannot complete some usual functions
Cannot complete most usual functions
Please list any functions that you have difficulty with.
*
Do you need help with personal care - dressing, bathing, feeding, walking?
*
Yes
No
IMPORTANT: A COMPANION guest MUST ACCOMPANY you as your CAREGIVER.
*
Yes, I understand.
Can you get into and out of bed on your own?
*
Yes
No
IMPORTANT: A COMPANION guest MUST ACCOMPANY you as your CAREGIVER.
*
Yes, I understand.
Are you strong enough to get into a high bathtub? (20 inches)
*
Yes
No
Do you have any problems with eating or your appetite?
*
Yes
No
If yes, please explain.
*
Have you been hospitalized in the last 6 months? If so, please explain.
*
Do you take any medications or supplements?
Yes
No
List ALL medications and supplements along with other information required.
*
Do you drink alcohol?
Yes
No
If so, what type, how often, and how much?
*
Do you smoke?
Yes
No
If so, how often and how much?
*
Back
Next
Save
Participant's Mental and Emotional Histories
Do you have any mental or emotional challenges?
*
Yes
No
Please select all that apply.
*
Anxiety
Bipolar
Dementia
Depression
PTSD
Severe Memory Loss
Other
How long have you had this problem?
*
What instigated the problem (if known)?
*
Do you have any behavioral/anger outbursts?
*
Yes
No
Have you been seen by a psychiatrist?
*
Yes
No
What is the problem/diagnosis from the psychiatrist?
*
How has the problem affected you (job, family, school, friendships, etc.)?
*
Are you on or have been on medication(s)? If so, which one(s)? What were (are) the effects on you?
*
Is there anything else we should know about?
*
Back
Next
Save
Companion's Personal Information
This portion is specifically for your companion. Please fill it out accordingly.
Companion's Legal Name
*
__
Mr.
Mrs.
Ms.
Miss
Prefix
First Name
Middle Name
Last Name
Main Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Email
*
Confirmation Email
MyEmail@example.com
Gender
*
Male
Female
Date of Birth
*
/
Month
/
Day
4-digit Year ex: 1970
Date Picker Icon
Age
*
Occupation
*
(If retired, include former occupation. Example: Retired Teacher)
Church Affiliation
*
How did you hear about Uchee Pines? Select all that apply.
*
A Friend
YouTube
Church
Other Social Media
Facebook
A Brochure, Poster, etc.
Twitter
A Live Stream, Zoom-type meeting, etc.
Email from Uchee Pines
I attended a previous Uchee Pines Conference/Seminar
Browsing Uchee Pines Website
Other
Please select your status
*
Level 1 / Medical Guest
Level 2/ Non-Medical Guest
Did a physician refer your companion to the program?
*
Yes
No
Physician's Name
*
First Name
Last Name
Physician's Contact Information
*
Have you previously seen or talked to a healthcare provider at Uchee Pines?
*
Yes
No
Select your preferred session dates for the Lifestyle Program you wish to attend.
*
Back
Next
Save
Companion's Physical Condition
Height
*
Examples: 5'2"
Weight
*
Example: 120 lbs
List ALL problems/diagnoses along with other information required.
*
How is your physical condition affecting you?
*
What is your level of functioning now?
*
Normal
Weak but can do everything
Cannot complete some usual functions
Cannot complete most usual functions
Do you need help with personal care - dressing, bathing, feeding, walking?
*
Yes
No
IMPORTANT: A COMPANION guest MUST ACCOMPANY you as your CAREGIVER.
*
Yes, I understand.
Can you get into and out of bed on your own?
*
Yes
No
IMPORTANT: A COMPANION guest MUST ACCOMPANY you as your CAREGIVER.
*
Yes, I understand.
Are you strong enough to get into a high bathtub? (20inches)
*
Yes
No
Do you have any problems with eating or your appetite?
*
Yes
No
If yes, please explain.
*
Have you been hospitalized in the last 6 months? If so, please explain.
*
Do you take any medications or supplements?
Yes
No
List ALL medications and supplements along with other information required.
*
Do you drink alcohol?
Yes
No
If so, what type, how often, and how much?
*
Do you smoke?
Yes
No
If so, how often and how much?
*
Back
Next
Save
Companion's Mental and Emotional Histories
Do you have any mental or emotional challenges?
*
Yes
No
Please select all that apply.
*
Anxiety
Bipolar
Dementia
Depression
PTSD
Severe Memory Loss
Other
How long have you had this problem?
*
What instigated the problem (if known)?
*
Do you have any behavioral/anger outbursts?
*
Yes
No
Have you been seen by a psychiatrist?
*
Yes
No
What is the problem/diagnosis from the psychiatrist?
*
How has the problem affected you (job, family, school, friendships, etc.)?
*
Are you on or have been on medication(s)? If so, which one(s)? What were (are) the effects on you?
*
Is there anything else we should know about?
*
Back
Next
Save
Please WAIT until you receive a CONFIRMATION from the Admissions Office that your APPLICATION is ACCEPTED before making any travel arrangements.
*
Okay, I will NOT make any travel arrangements before the Admissions Office contacts me.
Save
Submit
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