Referring Facility or Agency
If you are not currently in a facility, please proceed to nextthe section.
Facility or Agency NameText field
Facility AddressText field
Person Making ReferralText field
Contact NumberText field
Fax NumberText field
Referring Person's email Text field
Date of DischargeDate
Personal Application Information
What program are you requesting service from?Dropdown
Client NameClient first nameClient middle nameClient last name
Client AddressClient AddressClient CityClient StateClient Zip
Client PhoneClient phone
Date of BirthClient birthdate
SSNSSN
Email AddressText field
Second Contact NumberText field
Primary Insurance Provider Text field
Do you have VA MedicaidCheckboxes
VA Medicaid ID Number Text field
Date Bed NeededDate
Current Housing Needs
What is the applicant's current housing plans if not accepted at one of our facilities? Text field
Is the applicant at high risk for homelessness? Checkboxes
Criminal History
Has the applicant been convicted or accused of any violent offenses?Checkboxes
If so, please describe.Text field
Has the applicant been convicted or accused of any sexual offense?Checkboxes
If so, please describe.Text field
Screening Information
Has the applicant been free of substances for the past 30 days (or will they have completed a detox by the time of the requested admission)? Checkboxes
Estimated date of when they will have completed 30 days of detox.Date
Has the applicant been diagnosed with a substance use disorder (SUD)? Checkboxes
If so, please include the diagnosis (Dx codes are acceptable)
Client diagnosis
Client diagnosis
Will the resident be receiving Medication Assisted Treatment Services and/or will that follow up be scheduled prior to their discharge from current facility? Checkboxes
Potential Follow up ProviderText field
Are there any medical issues that are currently not under control or are being addressed by a physician? For example, uncontrolled diabetes, high blood pressure, chronic kidney disease? Complete medical portion or submit a copy of medical records. Medical records will be required for anyone deemed to need medical clearance. Client health problems
Is the applicant in need of mental health services?Checkboxes
Please list primary symptomsText field
Any current suicidal thoughts?Checkboxes
Any history of suicidal attempts? Checkboxes
WhenText field
If yes, was there a hospitalization?Checkboxes
Records May Be Required From That Facility Name of HospitalText field
Summarize why the applicant wants to receive services at our facility. Paragraph
Mini Health Questionnaire
General: Please Check all that apply
Checkboxes
Comments:
Text field
Skin: Please check all that apply
Checkboxes
Comments:
Text field
Head: Please check all that apply
Checkboxes
Comments:
Text field
Ears: Please check all that apply
Hard of Hearing:
Checkboxes
Earache:
Checkboxes
Ringing In Ears:
Checkboxes
Comments:
Text field
Eyes: Check all that apply
Checkboxes
Date of Last eye Exam: Text field
Nose: Check all that apply
Checkboxes
Comments:
Text field
Throat: Check all that apply
Checkboxes
Date of Last Dental Exam: Text field
Comments:
Text field
Neck: Check all that apply
Checkboxes
Comments:
Text field
Breasts: Check all that apply
Checkboxes
Comments:
Text field
Musculoskeletal: Check all that apply
Checkboxes
Do you use any assistive devices:
Checkboxes
Comments:
Text field
Respiratory: Check all that apply
Do you have a cough?
Checkboxes
Checkboxes
Do you have a C-Pap machine: Checkboxes
Comments:
Text field
Cardiovascular: Check all that apply
Checkboxes
Comments:
Text field
Gastrointestinal: Check all that apply
Checkboxes
Do you have an Ostomy? Checkboxes
If so, where is it placed? Text field
Can you manage the ostomy yourself? Checkboxes
Comments:
Text field
Urinary: Check all that apply
Checkboxes
Do you have a Urostomy? Checkboxes
If so, can you manage the urostomy yourself? Checkboxes
Comments:
Text field
Genital:
Checkboxes
Do you have any STDs? Checkboxes
If so, please list Text field
Comments:
Text field
Neurological: Check al that apply
Checkboxes
Comments:
Text field
Do you have a gambling disorder?Checkboxes
Do you have any food or medication allergies? Checkboxes
If so, please list Text field
Are you experiencing any Psychosis (Hallucinations/Auditory Hallucinations)?Checkboxes
If so, please explainText field
Are there any additional health concerns that you are experiencing that are not mentioned?Checkboxes
If so, please explainText field
I hereby affirm that the information in this document is correct and true to the best of my knowledge.
SignatureSignature