Compassionate Extended Care Resident Application

Resident Information
Full Name     First Name   Last Name   
Date of Birth    Type a label    Gender   Type a label   
Phone Number   Area Code   Phone Number   Email   Email   
Emergency Contact
Name   First Name   Last Name   Relationship   Type a label   
Phone   Area Code   Phone Number   Alternate Phone   Area Code   Phone Number   
Source of Income / Employment
   SSI   SSDI   Employment   Other    Type a label      
Monthly Income $   Type a label   
Move-In Date   Type a label   Preferred Room Type   Shared   Private   
Resident Signature    Signature   Date   Date   

Applicant Name   First Name   Last Name   
Current Address   Street Address   Address Line 2   City   State   Zip   
Phone   Area Code   Phone Number   Email   Email   
Employment or Income Verification
Employer   Type a label   Contact #   Area Code   Phone Number   
Monthly Income $   Type a label   Proof of Income   Yes   No   
Previous Residences (Last 2 Years)
Type a label   Dates   Date   –   Date   

Type a label   Dates   Date   –   Date   

Reason for Leaving Current Residence   Type a label   
Understanding House Rules   Agrees to Background Screening  
Signature   Signature   Date   Date   

 Resident Profile Sheet

Resident Name   First Name   Last Name   
Nickname/Preferred Name   Type a label      
Date of Birth   Date   Age   Type a label   
Physical Health Concerns / Allergies   Type a label   
Behavioral / Mental Health Notes (if any)   Type a label   
Support Services Currently Involved With
Case Manager      Name   Type a label   
Theraptist      Name   Type a label   
Probation Officer      Name   Type a label   
Goals During Stay:
Type a label   

Referring Agency / Person   Type a label   
Agency Phone #   Area Code   Phone Number   Email   Email   
Resident Referred For   Indepedent Living   Sober Living   Senior Housing      
Case Notes / Recommendations:   Type a label   
Referral Staff Signature   Signature   Date   Date   

Resident Name   First Name   Last Name   
Primary Emergency Contact   Type a label   
Relationship   Type a label   Phone   Area Code   Phone Number   
Secondary Contact   Type a label   
Relationship   Type a label   Phone   Area Code   Phone Number   
I authorize the program to contact the above in case of emergency and to release necessary information for safety purposes.
Resident Signature   Signature   Date   Date   
Witness   Signature   Date   Date   

I understand that participation in the program may require a background check for the safety of all residents.
I consent to a criminal background check.  
I have provided accurate information regarding any prior convictions.   
Signature   Signature   Date   Date