Date of Application
Altius Pl Llc
Independent Living Housing for the Elderly
Intake Coordinator:
PARTICIPANTS PERSONAL INFORMATION
Name
First Name
Last Name
Date of birth
Age
Phone number
Email Address
Current Address (Street, City, State,Zip
Gender
Male
Female
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EMERGENCY CONTACT
Emergency contact name
Relationship
Primary phone
Alternate phone
Address (If different from resident)
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MEDICAL INFORMATION
Participants are responsible for managing their own medications.
Primary Care Physician
Physician Phone
Current Medication (List All)
Accommodations - Please explain the accommodations needed?
Current Medication (List All)
Do you have any mobility limitation?
Yes
No
If yes, Please describe: (Assistive Devices)
Cane
Walker
Wheelchair
None
Any chronic medical conditions or disabilities?
Yes
No
If yes, Please describe: (Dietary Needs)
None
Diabetic
Low sodium
Vegetarian
Other
Cognitive Status
Independent
Mild impairment
Moderate impairment
Needs supervision
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PETS
Do you have any pet?
Yes
No
If yes, Type of pet and Breed
Any allergies or concerns related to animal:
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SHARED LIVING PREFERENCES
Shared or Private Room
Room Preference
Room Mate
Do you smoke
Do you require assistance with daily task
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COMPATIBILITY & PREFERENCE
Describe Your Daily Routine & Lifestyle?
What is important to you in a home environment?
How do you handle conflict or disagreement?
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FINANCIAL
Income Source
Social Security
Benefits
Retirement
Pension
Family Support
Others
Do you have insurance
Private Insurance
Medicaid
Medicare
Long term-care insurance
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PERSONAL REFERENCE
Reference 1
Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Reference 2
Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Resident Signature
Guidance / Representative
Submit
Submit
Should be Empty: