Resident Intake Form

ROAR FLORIDA APPLICATION

Please Fill Out Each Section and Upload Your Supporting Documents
Upload Your Supporting Documents Here*

Browse Files

Cancelof
Applicant Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Marital Status
Gender
Sex
Cell Phone*

Area CodePhone Number
Alternate Phone

Area CodePhone Number
Applicant E-Mail*
Name of Person Completing this Application
Relationship to Applicant
Phone Number of Person Completing Application*

Area CodePhone Number
Email of Person Completing Application*
example@example.com
Legal Representative

GuardianGuardian AdvocatePower of AttorneyRepresentative PayeeOther
Current Living Arrangment

Living in family household with parent/guardianLiving in Group HomeLiving in Assisted Living FacilityLiving independently in an apartment/house in the communityLiving with roommates in an apartment/house in the community
If currently living in a family home, group home or assisted living facility, has the applicant ever lived independently in the community?
If yes, how long?
How did you hear about ROAR Florida?*
Legal Representative or Primary Contact Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Which of the following best describes your (the applicants) disability?*

AutismCerebral PalsyIntellectually Disabled (Diagnosis prior to age 18)Prader-WilliSpina BifidaDown SyndromeDevelopmental Disability as defined in 393.063(12), Florida StatutesOther
If other please specify
Applicant Financial Status

Please indicate all funding streams the applicant receives and the monthly amounts.
Is the applicant currently employed
If so, where is applicant employed?
Estimated monthly income from employment:
Would this job continue if the applicant moved to ROAR Florida?
SSI (Supplemental Security Income)
Amount
SSD (Social Security Disability)
Amount
VA Benefits
Amount
Food Assistance Program (food stamps)
Amount
Special Needs Trust
Amount
Parent/guardian financial supplement
Amount
Does the applicant currently receive support services through the State of Florida?
If yes, please indicate source of funding:

Medicaid WaiverConsumer Directed Care (CDC)Other
Support Service Information

Personal Supports/ In-Home SupportsSupported Living CoachingAdult Day TrainingBehavior AnalysisHome Health CareSupported EmploymentResidential Habilitation (group home)Companion ServicesTransportation Services
Support Coordinator Name

First NameLast Name
Support Coordinator Phone Number

Area CodePhone Number
Is the applicant on the waitlist for Medicaid Waiver?
If yes, provide name and contact information below.
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Is the applicant on the waitlist list for Consumer Directed Care?
If yes, please provide name and contact information below.
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Does the applicant receive service through Department of Vocational Rehabilitation (VR)?
If yes, please provide name and contact information below.
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Applicant Skills:

Please rate the applicant's hygiene tasks

Showering

	Completely Independent	Needs Reminders	Needs Some Assistance	Needs Total Assistance	Not Applicable
Washing body well enough to ensure adequate hygiene
Washing hair and rinsing well enough to remove all shampoo and conditioner
Showers Daily

Toileting

	Completely Independent	Needs Reminders	Needs Some Assistance	Needs Total Assistance	Not Applicable
Gets to the restroom in time to prevent accidents
Adequately wipes/cleans self
Uses appropriate amount of toilet paper to prevent toilet clogs
Washes hands after using the restroom
Uses incontinence supplies correctly

Shaving

	Completely Independent	Needs Reminders	Needs Some Assistance	Needs Total Assistance	Not Applicable
Safely Shaves

Dressing

	Completely Independent	Needs Reminders	Needs Some Assistance	Needs Total Assistance
Chooses weather appropriate clothing
Puts on clothing correctly

Does the applicant require the use of Epi-Pen or other emergency treatment for allergic reaction?
Is the applicant able to administer Epi-Pen independently?
If yes, please list allergies?
Does the applicant have a history of seizures?
If yes, what type?
How long do the seizures last?
Mins
When was applicant's last seizure?
How often does the applicant experience seizures?
Describe how the seizures are managed:
(VNS, Rescue Meds, Daily Meds)
Can the applicant self-administer seizure medication without assistance?
Who currently schedules the applicant's medical appointments?
How does the applicant get to medical appointments?
Does the applicant use any adaptive equipment?
If yes, please check all that apply:

Power WheelchairScooterCane/CrutchesHearing Aid(s)Manual WheelchairWalkerGlasses/ContactsShower ChairOther
Does the applicant use splints?
If yes, what type?
Does the applicant use a communication device?
If yes, what type?
Dietary Needs & Skills
Does the applicant eat meals and snacks independently?
Does the applicant require any special dietary requirements?
If yes, describe:
Who is currently responsible for ensuring that the applicant follows dietary requirements?
Are there any meal time safety concerns for the applicant (Choking, aspiration, stuffing mouth, ect.)
If yes, please describe:
Does the applicant have an eating disorder (current or past)?
a. If yes, please describe the disorder and how it is managed:
b. If yes, when was the most recent episode and how long did it last?
Please rate applicant's dietary and cooking skills:

Meals and Cooking

	Completely Independent	Needs Reminders	Needs Some Assistance	Needs Total Assistance	Not Applicable
Prepared pre-packaged/ frozen food
Follows simple recipe
Shops for groceries
Heats/cooks food on stove or in oven
Uses microwave
Safely uses a sharp knife

Household Skills

Please rate applicant's household skills:

Household

	Completely Independent	Needs Reminder	Needs Some Assistance	Needs Total Assistance with	Not Applicable
Maintains clean living space
Maintains clean bathroom
Maintains clean kitchen and appliances

Laundry

	Completely Independent	Needs Reminder	Needs Some Assistance	Needs Total Assistance	Not Applicable
Does own laundry

Money Management Skills
Will the applicant pay his/her own bills if he/she moves into ROAR Florida without assistance?
If no, who will provide the assistance?
Who is the representative payee for the applicant's benefits?
Safety Skills
1. How long can applicant be left alone without supervision? (select the highest level of time possible)
2. Is the applicant able to sleep overnight without anyone checking on him/her?
3. Is the applicant able to secure his/her own apartment? (locking doors, ect.)
4. Does the applicant know how to identify a stranger and know what to do if approached by a stranger?
5. Can the applicant safely navigate to familiar places in the community without supervision?
6. Is the applicant able to cross the street or walk through a parking lot safely without assistance?
7. Does the applicant understand the concept of sexual consent?
8. Does the applicant understand safe sex and protection from pregnancy and sexually transmitted diseases (STDs)?
9. Does the applicant know to call the landlord or apartment complex for emergency maintenance needs (i.e. plumbing, leak, ect.)?
10. Does the applicant know how to safely evacuate the apartment in the event of an emergency?
11. Can the applicant use an app to access a non-emergency maintenance request and other ROAR communications?
Transportation Skills
1. How does the applicant typically get around the community? Check all that apply:

Drives a carRides a bikeWalksTakes a busTakes a door-to-door bus service (i.e. Citrus Connection)Takes a car service (Uber/Lyft)Driven by a family member/friend
2. Is the applicant able to follow simple directions to get somewhere?
3. Can the applicant arrange their own transportation to get somewhere when needed?
Mental Health and Behavioral Supports
1. Does the applicant currently receive psychiatric care?
2. Has the applicant ever received psychiatric care in the past?
3. Does the applicant have any mental health diagnosis?
a. If yes, please check all current and past mental health diagnosis:

Bipolar DisorderDepressionObsessive Compulsive DisorderBorderline Personality DisorderSchizophreniaAnxiety DisorderADHD/ADDIntermittent Explosive DisorderOther
b. If yes, How will the applicant continue the management of the condition(s)?

Self-injurious Behavior

	Within past 12 months	Within past 3 years	Longer than 3 years ago	Never exhibited
Head banging
Biting/cutting self
Hair pulling
PICA (eating non-food objects)
Suicidal talk/threats
Suicide attempt
Other self harm behaviors

If other self harm behaviors, please describe:

Aggressive Behavior

	Within past 12 months	Within past 3 years	Longer than 3 years ago	Never exhibited
Hits/Kicks others
Bites others
Uses weapons against others
Threatens/bullies others
Stalks/harasses others

Inappropriate Sexual behavior

	Within past 12 months	Within past 3 years	Longer than 3 years	Never exhibited
Exposing self to others
Touching others without consent
Public masturbation
Sexual interaction with minors (physical, verbal or online)
Making inappropriate sexual comments
Sending unwanted sexual communications (i.e. texts, videos, pictures, calls, notes)

Destruction of Property

	Within past 12 months	Within past 3 years	Longer than 3 years	Never exhibited
Damages/breaks own possession
Damages/breaks others possessions
Damages/breaks furniture or decor
Breaks windows
Sets fires

Inappropriate Social Behavior

	Within past 12 months	Within past 3 years	Longer than 3 years	Never exhibited
Throwing tantrums (stomping feet, sitting on the floor, aggressive gestures, ect.)
Cursing in appropriate settings
Stealing from others
Repetitive vocalizations
Yelling at others

5. Has the applicant's behaviors resulted in medical treatment for self or others?
6. Please describe how the applicant expresses frustration or anger:
7. Does the applicant have a current behavior plan?
a. If yes, what behaviors are identified in the plan?
b. Who assists in monitoring the plan?
8. Has the applicant ever gone missing?
a. If yes, were the police involved?
b. Where did the applicant go?
9. Has the applicant ever been treated under the Baker Act or other involuntary mental health treatment?
If yes, please provide frequency, all date(s) and reasons for treatment:
10. Has the applicant ever been arrested?
If yes, please provide date(s) and explanation:
11. Has the applicant ever been convicted of a crime?
If yes, please provide date(s) and explanation:
12. Is the applicant a registered sex offender?
If yes, does the applicant have any restrictions?
Additional Applicant Information
Is the applicant a smoker?
Has the applicant ever been asked to move out by a landlord?
Has the applicant ever breached a lease or rental agreement?
Has the applicant ever had an eviction filed against him/her?
Has the applicant intentionally refused to pay rent when due?
Does the applicant currently owe money to a landlord?
Has the applicant ever lost property in a foreclosure?
Has the applicant filed for bankruptcy
If yes, when?
Has the applicant ever been arrested for or convicted of a felony?
If yes, please explain?
Are there any criminal matters pending against the applicant?
If yes, please explain:
Expectations
Please describe why the applicant would like to live in one of the ROAR Florida properties:
I understand that the information provided will be used to assess suitability for independent living and confirm necessary support for the applicant to live independently with success.

I understand that completion of this application does not guarantee residency at a ROAR Florida property.

I understand that all information provided will be kept confidential and stored according to any regulatory requirements and/or best practices.

I agree that all the information provided on this application is true and accurate and that no information has been omitted.
Signature of applicant
Date/Time
Signature of person assisting with this application

Powered by Jotform SignClear
Signature

Powered by Jotform SignClear
Applicant Support Statement

ROAR Florida does not provide support services for our residents. Our applicants, their legal representatives, and their families acknowledge that there are certain areas where support is needed for an individual to be successful in an independent living community. Therefore, confirmation from the applicant and/or their legal representatives that adequate support is in place for independent living is required. Please indicate the support of the applicant below. (Note: If the appropriate level of support is not provided or maintained throughout the duration of the lease term, this may result in non-renewal of the lease.)
Medicaid Home and Community Based Wavier Services (MED WAIVER)
Applicant receives support services through the Florida Medicaid Waiver program and all adequate support services will be provided through that program.
*
prevnext( X )
Application Fee$75.00
Application fees are nonrefundable

Total $0.00
Medicaid Consumer Directed Care Service (CDC+)
Applicant receives support services through the Florida Medicaid Waiver program and all adequate support services will be provided through that program.
Consultant Name:

First NameLast Name
Phone Number

Area CodePhone Number
Representative Name:

First NameLast Name
Phone Number

Area CodePhone Number
Private Pay/Family Services
Applicant is not receiving support services through a government agency and is either privately paying a company to provide support services, or the family is providing and will continue to provide support services.
Support Provider Company Name:

First NameLast Name
Phone Number

Area CodePhone Number
Support Provider, Family, or Paid Provider Name:

First NameLast Name
Phone Number

Area CodePhone Number
By signing this, I agree to ensure support services are in place as indicated on the Applicant Support Statement. I understand that not having adequate support to be successful in an independent living community may result in non-renewal of the lease.
Applicant Signature

Powered by Jotform SignClear
Parent/Legal Represenative Signature

Powered by Jotform SignClear
Date/Time
Should be Empty:

ROAR FLORIDA APPLICATION

Legal Representative or Primary Contact Information

Applicant Financial Status

Applicant Skills:

Dietary Needs & Skills

Household Skills

Money Management Skills

Safety Skills

Transportation Skills

Mental Health and Behavioral Supports

Additional Applicant Information

Expectations

Applicant Support Statement