Referral Intake

Resident Information

1. Resident's First Name*

2. Resident's Last Name*

3. Resident's Date of Birth*

4. Resident's Age*

Please enter a number from 0 to 105.

5. Resident's Gender*

6. Dementia or Related Diagnosis?*

7. Guardianship Status:*

Primary reason for seeking residential services at Belong Health Care.*

Current Housing

8. Resident's Current Living Situation*

Other (please indicate)

Does the resident/client pay rent at current housing placement?*

How much is the rent at current housing?*

9. Approved allocation level*

10. Level of support requested*

Payment Method

We accept CADI or Elderly Waiver at move-in. Residents do not need to pay privately before moving in.

11. Who will pay your rent?*

12. Who will pay for the care services?*

13. Personal Income Source*

14. Personal Income Amount*

Has the resident/client been approved for Group Residential Housing (GRH) ?

Group Residential Housing (GRH) is a state-funded income supplement program that pays for room-and-board costs for low-income adults who have been placed in a licensed or registered setting with which a county human service agency has negotiated a monthly rate.

Case Management Team

15. Case Manager's First Name*

16. Case Manager's Last Name*

17. Case Manager's Phone #*

18. Case Manager's Email*

19. Rep Payee's First Name

20. Rep Payee's Last Name

21. Rep Payee's Phone #

22. Rep Payee's Email

Hidden

Medical Information

Hidden

What things are currently working well for the individual? (Routines, interests, hobbies)

Hidden

What are some of the current challenges?

Hidden

Level of Care Needed (Staffing Pattern)

Hidden

Special Needs (Dietary, Medical, Accessibility, etc.):

Additional Information

23. Floor Preference

24. Housemate Gender Preference

25. Room Preference

If you are willing to consider both a private room and a shared room, please check both boxes and discuss your preference with us during the tour.

26. Within what time frame would you like to make the move?

27. Home Preferences*

Assessment Documents Available

Your feedback helps our team develop the most comprehensive care plan for your client.

28. Select below the assessment and supporting documents available*

Comments or Special Reports

29. Does the person have any court-ordered treatment requirements or restrictions?

30. Does the resident/client have a Jarvis order?

31. Does the resident/client have a Guardianship order?

32. Does the resident/client have a Commitment order?

Interagency Transfer Details

This process comprises five steps: (1) develop a list of current medications; (2) develop a list of medications to be prescribed; (3) compare the medications on the two lists; (4) make clinical decisions based on the comparison; and (5) communicate the new list to appropriate staff and to the resident.

33. Do you know whether the person will have a current 3 day supply of medications?*

If no, please enter more info*

Phone

This field is for validation purposes and should be left unchanged.

(+1)651.705.6625

Resident Information

Current Housing

Payment Method

Case Management Team

Medical Information

Additional Information

Assessment Documents Available

Interagency Transfer Details