Resident Intake Form for Group Home Placement
Resident Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Non-Binary
Prefer Not to Say
Phone Number
*
Current Living Situation
Describe Current Living Situation
*
Health Information
Health Diagnosis
*
Physician Name
*
First Name
Last Name
Physician Location
*
Physician Phone Number
*
Medication and Therapy
Is the resident currently using medications or therapies?
*
Yes
No
If yes, please list the medications and therapies used:
How often are the medications taken?
*
Tuberculosis (TB) Test Requirement:
Has the resident completed a Tuberculosis (TB) test within the last 12 months?
*
Yes
No
If yes, please provide the date of the test:
If no, a TB test will be required before admission. Please provide proof of a completed TB test prior to the intake date.
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Last Physical Examination:
Has the resident had a physical examination within the last 12 months?
*
Yes
No
If yes, please provide the date of the last physical examination:
If no, a physical examination will be required before admission. Please provide proof of a completed physical examination prior to the intake date.
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Residential History
Has the resident stayed in a residential facility before?
*
Yes
No
If yes, please provide the facility name and location:
Expectations and Support
What are your expectations from our facility for the resident?
*
What specific accommodations or support does the resident need?
*
Legal and Behavioral Considerations
Are there any legal situations we should be aware of?
*
Yes
No
If yes, please provide details:
Does the resident have a history of violence, suicide attempts, or substance abuse?
*
Yes
No
If yes, please provide details:
Emergency Contacts
Primary Emergency Contact Name
*
First Name
Last Name
Primary Emergency Contact Phone Number
*
Please enter a valid phone number.
Secondary Emergency Contact Name
*
First Name
Last Name
Secondary Emergency Contact Phone Number
*
Please enter a valid phone number.
RSS Approval
Is the resident currently or in the process of being approved for RSS?
*
YES
NO
If yes, what was the assessment date?
When was RSS approved?
-
Month
-
Day
Year
Date
Financial Information
Does the resident have a payee?
*
YES
NO
If yes, please provide the payee's name and contact information:
Case Manager/Social Worker Contact Information
Case Manager/Social Worker #1 (Name)
*
First Name
Last Name
Case Manager/Social Worker #1 (Phone)
*
Please enter a valid phone number.
Case Manager/Social Worker #1 (Email)
*
example@example.com
Case Manager/Social Worker #2 (Name)
First Name
Last Name
Case Manager/Social Worker #2 (Phone)
Please enter a valid phone number.
Case Manager/Social Worker #2 (Email)
example@example.com
Case Manager/Social Worker #3 (Name)
First Name
Last Name
Case Manager/Social Worker #3 (Phone)
Please enter a valid phone number.
Case Manager/Social Worker #3 (Email)
example@example.com
Additional Information
Expected Move-In Date:
*
-
Month
-
Day
Year
Date
What concerns or questions do you have for us now?
*
*Your signature above indicates that the information you have provided above is truthful.
Submit
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