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):
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.
Is the resident approved or in process for RSS (Residential State Supplement)?
Yes
No
Pending
Medical & Behavioral Health History
Does the resident require assistance with any of the following? (Check all that apply)
*
Cooking
Cleaning
Medication management
The resident requires 24-hour skilled nursing care
Not sure about the need for 24-hour skilled nursing care
No assistance required at this time
Other
Does the resident have any medical conditions?
*
Yes
No
If yes, please describe:
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:
Select all that apply to the resident
*
Has a history of active substance use
Requires detox services
May have difficulty following AFLH house rules
May not be safe in a non-locked, community-based setting
Has a history of leaving care without notice (elopement)
Unsure about elopement, safety, or rule compliance
None of these
Other
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
File Upload
Browse Files
Drag and drop files here
Choose a file
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Signature
Medication History & Compliance
Has the resident ever refused or forgotten to take prescribed medications?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
PRN (As-Needed) Medication Use
Is the resident prescribed any PRN (as-needed) medications?
*
Yes
No
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?
*
Yes
No
If yes, please describe:
Does the resident have a history of aggressive behavior or self-harm?
*
Yes
No
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 Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Dates of Stay (From – To):
*
Reason for Leaving:
*
Placement 2 Name:
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Dates of Stay (From – To):
*
Reason for Leaving:
*
Placement 3 Name:
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Dates of Stay (From – To):
*
Reason for Leaving:
*
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.
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