Resident Intake Form for Group Home Placement
Personal Information
Full Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Non-Binary
Prefer Not to Say
Social Security Number (SNN)
*
Height
*
Weight
*
Telephone Number
*
Email Address
*
example@example.com
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Residence Information
Check one below to indicate where the resident currently lives.
*
Family/Friend’s Home
Assisted Living
Nursing Home
Hospital
Shelter
Other (please specify):
Please provide contact information for the resident’s primary caregiver or personal advocate
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Relationship to Resident
*
Has the resident been assigned a Case Manager or Social Worker?
*
Yes
No
Name
Organization
Phone Number
Please enter a valid phone number.
Has the resident been approved for RSS (Residential State Supplement)?
Yes
No
In Process
Medical & Behavioral Health History
Does the resident require assistance with any of the following? (Check all that apply)
*
Cleaning
Meal Preparation
Medication management
24-hour skilled nursing care
Not sure about the need for 24-hour skilled nursing care
No assistance required
Other
Does the resident have any medical conditions?
*
Yes
No
If yes, please describe:
Is the resident currently taking medication(s)?
*
Yes
No
If yes, please list medications:
Does the resident have a history of mental illness?
*
Yes
No
If yes, please describe:
Has the resident ever been hospitalized for mental health concerns?
*
Yes
No
If yes, date & reason:
Has the resident ever been convicted of a felony or misdemeanor? ☐
*
Yes
No
If yes, please provide details:
Please select all that apply to the resident
*
Has a history of active substance use
Requires detox from substance use
May have difficulty following RFH house rules
May not be safe in an unlocked, community-based setting
Has a history of leaving care without notice (elopement)
Unsure about elopement, safety, or rule compliance
None of these
Other
Financial Information
Does the resident receive any financial assistance?
*
Yes
No
Does the resident receive any financial assistance?
*
SSDI
SSI
Veterans Benefits
Other
Does the resident have a designated payee?
*
Yes
No
If yes, Name:
*
Relationship:
*
Phone Number
*
Please enter a valid phone number.
Medical Records & Required Documentation
Does the resident have a recent (within the last year) TB test?
*
Yes
No
Does the resident have a recent (within the last year) physical exam?
*
Yes
No
Authorization for Medical Records Release: I authorize Red Fern Haven to request and obtain medical records from my healthcare providers for the purpose of resident intake and care planning.
Yes
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Signature
Medication History
Has the resident ever refused or forgotten to take prescribed medications?
*
Yes
No
If yes, what was the reason for not taking medication in the past?" (e.g., side effects, confusion, no supervision)
Medication Routine
Does the resident require reminders or supervision to take medications?
*
Yes
No
Has the resident been compliant with medications in their current or most recent placement?
*
Medical Equipment
Does the resident use any medical devices regularly?" (e.g., CPAP machine, nebulizer, insulin pump)
*
Does the resident need assistance using this equipment?
*
Yes
No
PRN (As-Needed) Medication
Is the resident prescribed any PRN (as-needed) medications?
*
Yes
No
If yes, for what symptoms?
Pharmacy and Prescription
What pharmacy does the resident currently use?
*
Are there any issues with medication delivery, insurance coverage, or refill delays?
*
Medication Side Effects or Allergies
Has the resident experienced side effects from any medications?
*
Are there known medication allergies or sensitivities?
*
Behavioral Support & Special Needs
Does the resident require any accommodations or special assistance?
*
Yes
No
If yes, please describe:
Does the resident have a history of aggressive behavior or self-harm?
*
Yes
No
If yes, please describe:
Placement History
Please list the resident's last three residential placements (group home, supportive housing, shelter, or facility). If the resident has lived in at least one facility, please complete Placement 1. Only complete Placement 2 and Placement 3 if applicable. Otherwise, leave them blank. If the resident has no prior facilities, enter “N/A” in the "Placement 1 Name" field.
Placement 1 Name:
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Duration of Stay (month/year – month/year):
Reason for Leaving:
Placement 2 Name:
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Duration of Stay (month/year – month/year):
Reason for Leaving:
Placement 3 Name:
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Duration of Stay (month/year – month/year):
Reason for Leaving:
Referral Information
How did you hear about our group home?
*
Online
Friend/Family
Case Worker
Hospital
Shelter
Other:
Other: please specify
Who referred the resident?
Name
*
First Name
Last Name
Organization
*
Contact Number
*
Please enter a valid phone number.
I consent to being contacted by Red Fern Haven regarding my placement status via:
*
Phone
Email
Text
*
I understand that I am not guaranteed placement by completing this form.
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