Ricky's Place Care Home - Resident Application (web)

RICKY'S PLACE - Resident Application (web)

Please complete this application accurately and in full.
HOW DID YOU HEAR ABOUT US?*
REFERRING PERSONS NAME*
REFERRING AGENCY NAME*
WHO ARE YOU APPLYING FOR?

THANK YOU FOR YOUR CONSIDERATION
A WORD FROM OUR FOUNDERS

Thank you for considering Ricky's Place Care Home as your new residence. Our community is dedicated to providing exceptional care and support to all our residents. We believe in going above and beyond with a resident-first mentality, ensuring that every action prioritizes your well-being and dignity.

At Ricky's Place, we strive to create an environment where every resident feels valued and respected. We are committed to making our community a place where you can prosper and feel truly appreciated. We look forward to the possibility of welcoming you to our supportive and compassionate environment.

Sincerely,
Ricky's Place Care Home

RESIDENT INFORMATION
APPLICANT NAME*

First NameLast Name
PHONE NUMBER*
Please enter a valid phone number.
EMAIL ADDRESS*
example@example.com
APPLICANT HOME ADDRESS*

Street Address

Street Address Line 2

CityState

Zip Code
APPLICANT BIRTHDATE*

MonthDayYear
Date

RESPONSIBLE PARTY INFORMATION
RESPONSIBLE PARTY NAME*

First NameLast Name
PHONE NUMBER*
Please enter a valid phone number.
EMAIL ADDRESS*
example@example.com
RESPONSIBLE PARTY NAME HOME ADDRESS*

Street Address

Street Address Line 2

CityState

Zip Code
RESPONSIBLE PARTY BIRTHDATE*

MonthDayYear
Date
Relationship to Applicant*
RESPONSIBLE PARTYS LEGAL STANDING TO APPLYING RESIDENT? (check all that apply)*

GuardianPower of AttorneyOther
Do You Have Immediately Available Legal Documents to Confirming This Status?*

YesNo

FINANCIAL DISCLOSURE
WE ARE A PRIVATE PAY ONLY FACILITY

At Ricky's Place Care Home, we do not accept any form of private or public insurance, including but not limited to Medicaid, Medicare, and any other state or federal insurance programs.

Our services are exclusively available on a private pay basis. As such, the resident and/or the responsible party will be fully responsible for all fees, charges, and related expenses.

Sincerely,
Ricky's Place Care Home
OUR FEE STRUCTURE

Ricky's Place Care Home, our fees are determined based on a combination of the room base rate and the specific needs of each resident. We are a private room-only facility, and the room base rate is influenced by the size of the room.

Additional charges are assessed based on the resident's day-to-day health requirements and activities of daily living (ADL) needs.

The below assessment is to determine the general needs of the applying resident. A more thorough health assessment and examination by a licensed healthcare professional will take place to determine the full fees.

This approach allows us to ensure that each resident receives personalized care and support tailored to their individual circumstances.

Sincerely,
Ricky's Place Care Home
Do You Accept and Understand that we do not accept any form of private or public insurance, including but not limited to Medicaid, Medicare, and any other state or federal insurance programs. As such, the resident and/or the responsible party will be fully responsible for all fees, charges, and related expenses.
Do You Accept and Understand that This Assessment is to determine general Applying Resident Needs and that a more thorough access will be complete before admittance to determine full fees?

MEDICATIONS
How Many Medications Does the Applying Resident Take Daily?*

None1-34-67-1011+
Does the Applying Resident Require Assistance Physically Taking Medications?*

YesNo
Does the Applying Resident Require Assistance Remembering When to Take Medications?*

YesNo

SIGNATURE
By signing below, I hereby acknowledge and certify that the information I have provided in this partner application is true and accurate to the best of my knowledge.

I also acknowledge that I am aware that intentionally providing false, fraudulent, misleading, or incorrect information in this application can result in rejection of resident application, termination of residency, change in service fees, and other consequences at any time now or in the future.
APPLICANT NAME*

First NameLast Name
Signature*

Clear
REPONSIBLE PARTY NAME*

First NameLast Name
Signature*

Clear
TODAYS DATE

MonthDayYear
Should be Empty:

	Yes	No
Alzheimers
Confusion
Dementia
Forgetfullness
Initiating activities
Judgment
Memory
Organization
Orientation to time, person or place
Planning
Wandering
Other Unlisted Issues

	Yes	No
Addictive Behaviors
Anxiety
Attention Deficit Hyperactivity Disorder (ADHD)
Autism
Bi-polar
Depression
Drug Abuse
Eating Disorders
Obsessive Compulsive disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Schizophrenia
Suicidal Thoughts

	Yes	no
Aggressive Grumbling/Complaining
Hit or Become physical with others
Threaten others
Throw or break things
Swear at others
Walk away
None Of The Above

	Fully Independent	Requires Some Supervision/Assistance	Requires Full Assistance
Bathing
Brushing Teeth or Cleaning Dentures
Brushing and/or styling hair
Cleaning room/home
Cooking
Dressing
Getting in and out of bed
Getting in and out of a chair
Getting in and out of the shower/tub
Getting on and off the toilet
Grooming/Shaving
Feeding self
Laundry
Reading
Toileting
Using Telephone
Writing
Walking

RICKY'S PLACE - Resident Application (web)

THANK YOU FOR YOUR CONSIDERATION

RESIDENT INFORMATION

RESPONSIBLE PARTY INFORMATION

FINANCIAL DISCLOSURE

Physical Health Assessment

Mental Health Assessment #1

Mental Health Assessment #2

MEDICATIONS

Activities of Daily Living

SIGNATURE