Resident Intake Form for Group Home Placement

Resident Intake Form for Group Home Placement
Personal Information
Full Name

First NameLast Name
Birth Date

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Residence Information
Check one below to indicate where the resident currently lives.

Other (please specify):
Please provide contact information for the resident’s primary caregiver or personal advocate
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Resident
Has the resident been assigned a Case Manager or Social Worker?
Name
Organization
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Has the resident been approved 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:
Please 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 Red Fern Haven 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
Has the resident ever refused or forgotten to take prescribed medications?
If yes, what was the reason for not taking medication in the past?" (e.g., side effects, confusion, no supervision)
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
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
Is the resident prescribed any PRN (as-needed) medications?
If yes, for what symptoms?
Pharmacy and Prescription
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

Please list the resident's last three residential placements (group home, supportive housing, shelter, or facility). If the resident has lived in at least one facility, please complete Placement 1. Only complete Placement 2 and Placement 3 if applicable. Otherwise, leave them blank. If the resident has no prior facilities, enter “N/A” in the "Placement 1 Name" field.
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.
Duration of Stay (month/year – month/year):
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.
Duration of Stay (month/year – month/year):
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.
Duration of Stay (month/year – month/year):
Reason for Leaving:
Referral Information
How did you hear about our group home?
Other: please specify
Who referred the resident?
Name

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

Resident Intake Form for Group Home Placement

Personal Information

Residence Information

Please provide contact information for the resident’s primary caregiver or personal advocate

Medical & Behavioral Health History

Financial Information

Medical Records & Required Documentation

Medication History

Medication Routine

Medical Equipment

PRN (As-Needed) Medication

Pharmacy and Prescription

Medication Side Effects or Allergies

Behavioral Support & Special Needs

Placement History

Referral Information

Who referred the resident?