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:*SelfPrivatePublicPrimary reason for seeking residential services at Belong Health Care.*Current Housing8. Resident's Current Living Situation*Group HomePrivate Home/AptFoster CareBoard & LodgeIRTRTCNursing HomeHomeless/ShelterJail/PrisonAssisted LivingOtherOther (please indicate) Does the resident/client pay rent at current housing placement?*YesNoHow much is the rent at current housing?* 9. Approved allocation level*Community Residential ServicesCustomized Living - HouseCustomized Living - Single Bedroom24-Hour Emergency Assistance10. Level of support requeste*Community Residential Services (24 hrs)Customized Living (12-16 hrs)Customized Living - Single Bedroom (8-10 hrs)24-Hour Emergency AssistancePayment MethodWe accept CADI or Elderly Waiver at move-in. Residents do not need to pay privately before moving in.11. 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 PayOther12. Who will pay for the care services?*CADICACDDEWBIPrivate PayPending SMRTOther13. 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.YesNoCase Management Team15. 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 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 Information23. Floor PreferenceFirst FloorMain FloorLower Level24. Housemate Gender PreferenceMales OnlyFemales OnlyMixed Gender25. Room 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.26. Within what time frame would you like to make the move? 27. Home Preferences*Can climb stairs without assistive deviceHandicap accessible spaceAssessment Documents AvailableYour feedback helps our team develop the most comprehensive care plan for your client.28. Select below the assessment and supporting documents available* ① MnCHOICES Assessment ② Coordinated Service and Support Plan (CSSP) ③ Community Support Plan (CSP) ④ Psychiatric or diagnostic assessment ⑤ Hospitalization notes ⑥ Medical and mental health history notes ⑦ Behavioral assessments and support plans ⑧ Psychological/neuropsychological assessments ⑨ Civil commitment orders ⑩ Provisional discharge agreements; and/or ⑪ Functional assessments ⑫ Positive Behavior Support Plan Comments or Special Reports29. Does the person have any court-ordered treatment requirements or restrictions?YesNo30. Does the resident/client have a Jarvis order?YesNo31. Does the resident/client have a Guardianship order?YesNo32. Does the resident/client 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 staff and to the resident.33. 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* NameThis field is for validation purposes and should be left unchanged.