ADULT INTAKE FORM

ADULT INTAKE FORM - AFLH
Resident Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Height
Weight
Social Security Number (SNN)
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Person (Submitter Name)

First NameLast Name
Contact Person (Submitter Email)
example@example.com
Current Living Situation
Where is the resident currently residing?

Other (please specify):
Who is the resident’s primary caregiver or support person?
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Resident
Does the resident have a Case Manager or Social Worker?
Name
Organization
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is the resident approved or in process for RSS (Residential State Supplement)?
Medical & Behavioral Health History
Does the resident require assistance with any of the following? (Check all that apply)

Other
Does the resident have any medical conditions?
If yes, please describe:
Is the resident currently taking medication(s)?
If yes, please list medications:
Does the resident have a history of mental illness?
If yes, please describe:
Has the resident ever been hospitalized for mental health concerns?
If yes, date & reason:
Has the resident ever been convicted of a felony or misdemeanor? ☐
If yes, please provide details:
Select all that apply to the resident

Other
Financial Information
Does the resident receive any financial assistance?
Does the resident receive any financial assistance?
Does the resident have a designated payee?
If yes, Name:
Relationship:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Records & Required Documentation
Does the resident have a recent (within the last year) TB test?
Does the resident have a recent (within the last year) physical exam?
Authorization for Medical Records Release: I authorize Group Home to request and obtain medical records from my healthcare providers for the purpose of resident intake and care planning.
File Upload

Cancelof
Signature
Medication History & Compliance
Has the resident ever refused or forgotten to take prescribed medications?
If yes, what was the reason for past non-compliance?" (e.g., side effects, confusion, lack of supervision)
Current Medication Routine
Does the resident require reminders or supervision to take medications?
Has the resident been compliant with medications in their current or most recent placement?
Medical Equipment Use
Does the resident use any medical devices regularly?" (e.g., CPAP machine, nebulizer, insulin pump)
Does the resident need assistance using this equipment?
PRN (As-Needed) Medication Use
Is the resident prescribed any PRN (as-needed) medications?
If yes, for what symptoms?
Pharmacy and Prescription Details
What pharmacy does the resident currently use?
Are there any issues with medication delivery, insurance coverage, or refill delays?
Medication Side Effects or Allergies
Has the resident experienced side effects from any medications?
Are there known medication allergies or sensitivities?
Behavioral Support & Special Needs
Does the resident require any accommodations or special assistance?
If yes, please describe:
Does the resident have a history of aggressive behavior or self-harm?
If yes, please describe:
Placement History

List the resident's last three residential placements (group home, supportive housing, shelter, or facility):
Placement 1 Name:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Dates of Stay (From – To):
Reason for Leaving:
Placement 2 Name:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Dates of Stay (From – To):
Reason for Leaving:
Placement 3 Name:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Dates of Stay (From – To):
Reason for Leaving:
Referral Information
How did you hear about our group home?
Other please specify
Who referred the resident (if applicable)?
Name

First NameLast Name
Organization
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
I consent to being contacted by [Group Home Name] regarding my placement status via;
Should be Empty:

ADULT INTAKE FORM - AFLH

Resident Information

Current Living Situation

Who is the resident’s primary caregiver or support person?

Medical & Behavioral Health History

Financial Information

Medical Records & Required Documentation

Medication History & Compliance

Current Medication Routine

Medical Equipment Use

PRN (As-Needed) Medication Use

Pharmacy and Prescription Details

Medication Side Effects or Allergies

Behavioral Support & Special Needs

Placement History

Referral Information

Who referred the resident (if applicable)?