Resident Information1. 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*MaleFemaleTransgenderOther6. Dementia or Related Diagnosis?*YesNo7. Guardianship Status:*SelfPrivatePublicCurrent HousingResident's Current Living Situation*Group HomePrivate Home/AptFoster CareBoard & LodgeIRTRTCNursing HomeHomeless/ShelterJail/PrisonOtherOther (please indicate) Level of support requested*Community Residential Services (24 hrs)Customized Living (12-16 hrs)Customized Living - Single Bedroom (8-10 hrs)24-Hour Emergency AssistanceApproved allocation level*Community Residential ServicesCustomized Living - HouseCustomized Living - Single Bedroom24-Hour Emergency AssistancePayment MethodWe accept CADI or Elderly Waiver at move-in. Residents do not need to pay privately before moving in.Who will pay your rent?*Supplemental Security Income (SSI)Social Security Disability Insurance (SSDI)Community Access for Disability Inclusion (CADI) WaiverGroup Residential Housing (GRH)Private PayOtherWho will pay for the care services?*CADICACDDEWBIPrivate PayPending SMRTOtherPersonal Income Source* Personal Income Amount*Case Management TeamCase Manager's First Name* Case Manager's Last Name* Case Manager's Phone #* Case Manager's Email* Rep Payee's First Name Rep Payee's Last Name Rep Payee's Phone # Rep Payee's Email HiddenMedical InformationHiddenWhat things are currently working well for the individual? (Routines, interests, hobbies)HiddenWhat are some of the current challenges?HiddenLevel of Care Needed (Staffing Pattern)HiddenSpecial Needs (Dietary, Medical, Accessibility, etc.):Additional InformationFloor PreferenceFirst FloorMain FloorLower LevelHousemate Gender PreferenceMales OnlyFemales OnlyMixed GenderRoom PreferencePrivate RoomShared RoomIf 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.Within what time frame would you like to make the move? Home Preferences*Can climb stairs without assistive deviceHandicap accessible spaceAssessment Documents AvailableSelect below* ① MNChoices Assessment ② Coordinated Service and Support Plan (CSSP) ③ Psychiatric or diagnostic assessment ④ Hospitalization notes ⑤ Medical and mental health history notes ⑥ Behavioral assessments and support plans ⑦ Psychological/neuropsychological assessments ⑧ Civil commitment orders ⑨ Provisional discharge agreements; and/or ⑩ Functional assessment Comments or Special ReportsDoes the person have any court-ordered treatment requirements or restrictions?YesNoDoes the person have a Jarvis order?YesNoDoes the person have a Guardianship order?YesNoDoes the person have a Commitment order?MIMI/CDMI/DNoInteragency Transfer DetailsThis 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 caregivers and to the patient.Do you know whether the person will have a current 3 day supply of medications?*YesNoNot taking meds at this timeIf no, please enter more info* CAPTCHACommentsThis field is for validation purposes and should be left unchanged.