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
Height
*
Weight
*
Social Security Number (SNN)
*
Phone Number
*
Email Address
*
example@example.com
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Living Situation
Where is the resident currently residing?
*
Shelter
Hospital
Family/Friend’s Home
Nursing Home
Independent Living
Other (please specify):
Other (please specify):
Who is the resident’s primary caregiver or support person?
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Relationship to Resident
*
Does the resident have a Case Manager or Social Worker?
*
Yes
No
Name
Organization
Phone Number
Please enter a valid phone number.
Medical & Behavioral Health History
Does the resident have any medical conditions?
*
Yes
No
If yes, please describe:
Does the resident require assistance with daily activities (e.g., cooking, cleaning, medication management)?
*
Yes
No
Is the resident currently taking medication(s)?
*
Yes
No
If yes, please list medications:
Does the resident have a history of mental illness?
*
Yes
No
If yes, please describe:
Has the resident ever been hospitalized for mental health concerns?
*
Yes
No
If yes, date & reason:
Has the resident ever been convicted of a felony or misdemeanor? ☐
*
Yes
No
If yes, please provide details:
Financial Information
Does the resident receive any financial assistance?
*
Yes
No
Does the resident receive any financial assistance?
*
SSI
SSDI
Veterans Benefits
Other
Does the resident have a designated payee?
*
Yes
No
If yes, Name:
Relationship:
*
Phone Number
*
Please enter a valid phone number.
Medical Records & Required Documentation
Does the resident have a recent (within the last year) TB test?
*
Yes
No
Does the resident have a recent (within the last year) physical exam?
*
Yes
No
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.
Yes
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Behavioral Support & Special Needs
Does the resident require any accommodations or special assistance?
*
Yes
No
If yes, please describe:
Does the resident have a history of aggressive behavior or self-harm?
*
Yes
No
If yes, please describe:
Referral Information
How did you hear about our group home?
*
Case Manager
Hospital
Shelter
Friend/Family
Online
Other:
Other please specify
Who referred the resident (if applicable)?
Name
*
First Name
Last Name
Organization
*
Contact Number
*
Please enter a valid phone number.
I consent to being contacted by [Group Home Name] regarding my placement status via;
*
Phone
Email
Text
*
I understand that completion of this form does not guarantee placement.
Continue
Continue
Should be Empty: