Camphill Village Minnesota Application Form
Camphill Village MN 15136 Celtic Drive. Sauk Centre, MN, 56378, (320)732-6365
Personal Information
Applicant Name
*
First Name
Last Name
Birthday
*
-
Month
-
Day
Year
Date
Age
*
Gender
*
Male
Female
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Condition causing disability
*
Present since
*
Guardian Information
Case manager and Funding resources
Guardian 1
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Guardian 2
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Guardian Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Case Manager Information
*
Case Managers Name, Address, phone number and Email address
Funding Source
*
CADI
CAC
DD
BI
Private Pay
Other
Admission Application Form
Please explain the Applicants current situation in the following areas
How did you hear about Camphill Village Minnesota
*
What attracted you to our community?
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Home Life
*
Where have you been living? Please, describe your life skills and your needs
Work Life
*
Have you been working and where? Please describe your working skills and your needs while working
Nutritional Management
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How are you with eating well balanced meals? Anything that we need to know about dietary restrictions or eating non-food items?
Household management
*
how are you with activities such as cooking, cleaning, budgeting and maintenance tasks
Community Orientation
*
How do you get around in the community? Can you be alone in the community and for how long?
Time management
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Can you tell time? Are you on time for appointments?
Mobility
*
Do you require mobility equipment? Please describe if you have a mobility or safety problem.
Safeguarding Cash Resources
*
how do you handle cash, checking and savings accounts?
Safety/Self Defense
*
are you able to evacuate independently during a fire drill or take precautions during a tornado drill. Are you able to defend yourself against others that may be aggressive towards you?
Personal and Healthcare Management
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how well do you take care of yourself such as grooming, brushing teeth, eating, bathing and doing laundry
Interpersonal Relationships
how do you get along with people
Communication
do you have a problem with communication: Speech? Hearing? Vision?
Medications/Medication Management
please list medications and how you manage the medications
Any Behavioral Issues
are there any behaviors that should be known to the admitting provider? Sexual behavior disorder?
Civic Awareness/Public Assistance/Legal Rights
What services are you on, Medicaid, Medicare, SSI, SSDI, RSDI, any legal issues
Activities
Do you enjoy participating in group activities, please elaborate
Problem Solving Skills
what are the problem-solving skills you have?
What aspects of community life would be particularly challenging to you
How do you respond to frustration and/or emotional distress?
Do you have a tendency to wander off or run away? Please explain to us :-)
Do you have any obsessions or compulsions? Please elaborate.
Do you have or display any aggressive/manipulative or (self) abusive tendencies. (If yes, please describe in detail, including frequency, severity, etc.)
Who are two to three friends or family or case manager who are closely supportive of you?
What way makes you feel supported and closed to you
Is there anything else you would like us to know about you? Please Include anything that you think is relative to help us know and understand who you are such as early history, family relationships, important life experiences.
Who is completing this application form, and which email address should we use to contact you?
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