Facebook

Check Bridge Openings

SPONSORED RESIDENTIAL INTAKE FORM

 

Date:                 Person Completing Form: 

Relationship to Individual:

Contact information:   Phone:      Cell:    Fax:

Email address:

Referral for:

Information                    Seeking Sponsored Placement support          

Other (list)

Preferences (if known Ė please include preferred City/County):

Presenting Needs:

 

DEMOGRAPHICS:

Individualís Name:        Date of Birth:

Current Address:                           Gender:  M  F

Living Arrangements:   W/Family      Congregate Sponsored Placement    Congregate Group Home

Institution (please list) 

Social Security #     Medicaid #   Medicare #

Supplement Insurances  

Is there a Legal Guardian?            Yes    No

If yes, list County, personís name, address and contact numbers:

Representative Payee information: Name:    Phone:

Address:

Banking Institution, Account # and balance will be requested prior to transfer. Planning for funds transfer/accounting will be made upon acceptance into The family Center Of Hope

Primary ID/DD Diagnosis:    Other:

Funding Source: (i.e. ID or DD Waiver, DAP)

 

Signature:     Date:
                 
I understand that checking this box constitutes a legal signature.

ACCOMPANYING DOCUMENTATION TO BE FORWARDED TO THE FAMILY CENTER OF HOPE

Consent to Exchange Information       IDOLS               Medicaid#     Medicare Plan card    LOF

Social Assessment      Psychological               Current treating physician      Current ISP

Current Physical          Current medication list

Follow Up: Date:                Program Coordinator: