Brinkley Haven Resident Admission & Intake Form

Resident Admission & Intake Form
Name*

First NameLast Name
Middle
Date of Birth*

MonthDayYear
Date
Age
RaceEthnicity
Social Security#*
Drivers License # or ID # and State
Prior Address
City
State
ZIP
Phone
Email
example@example.com
2. Family Member / Legal Guardian
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Relation to Resident
Phone Number*
Email*
example@example.com
Address
City
State
ZIP
3. Physician and Day program information:
Primary Physician Name*
Primary Physician Phone number*
Physician Address
Name and Address of Day Program if any
Policy Info:
Policy Number
Insurance Provider
Insurance Phone #
Group Name
Group Number
Insureds Name
Relation to Resident
Date of Birth

MonthDayYear
Date
Does the resident Receive SSI or SSDI?

YesNo
Responsible paying party*
First name and last name
Phone Number
Email
example@example.com
Date of Birth

MonthDayYear
Date
Relation to Resident
Address
City
State
ZIP
Resident Preferences & Needs
Dietary Restrictions or Preferences
Hobbies Interests
Religious or Spiritual Preference
Mobility:

IndependentCaneWalkerWheelchair
Hearing:

NormalHard of HearingDeaf
Vision:

NormalImpairedBlind
Communication:

VerbalNon-Verbal
Cognitive Status:*

AlertMild DementiaAlzheimer'sOther
PAYMENT & MOVE-IN ACKNOWLEDGMENT
Statement:
A $1,500 non-refundable administrative fee is required prior to move-in.
Monthly rent will be prorated and charged on Wednesday.

I acknowledge and agree to the payment terms.
Resident or responsible party signature*

Clear
Date*

MonthDayYear
Date
Please feel free to upload the following if you can: ID/Driver license

Cancelof
Social Security Card

Cancelof
Insurance Card

Cancelof
Medication List

Cancelof
Guardian/POA forms

Cancelof
Medical Information from doctor

Cancelof
Should be Empty: