* Required Information
Application for Group Home Admission

Applicant refers to the name of the individual being considered.

It is our policy to admit and treat all applicants without regard to race, color, national origin, religion, creed, age, sex, sexual orientation, ancestry, or physical or mental disability.

REFERRAL DATA
SIS Information
BIOGRAPHICAL INFORMATION
PARENTS
Siblings/Significant Others
OTHER CONTACT INFORMATION
Consulting Physicians (Cardiologist, Psychiatrist, Dermatologist, Neurologist, Dentist, Etc.)
COLLATERAL AGENCIES

Please list any other providers (nursing, vocational, educational, etc.) currently working with the applicant.

Please list the Dates Received for the following vaccinations: (*The following vaccines are required for admissions into AccessStar Programs). Please attach medical record as applicable.
EDUCATION AND EMPLOYMENT HISTORY
Title of last 2 jobs held and the date of employment
HOUSING
CURRENT MEDICAL/PSYCHIATRIC HISTORY
Behavior
History of Applicant (including current status)
Previous Incarceration
Mental Illness/Psychiatric Treatment
Alcohol or Drug Abuse
Infectious Diseases (MRSA, HIV, Hepatitis, TB, etc.)
Other Hospitalizations
Present Conditions
CURRENT MEDICATIONS
LIST ANY NON-PRESCRIPTION MEDICATIONS, VITAMINS, REMEDIES OR HERBS YOU TAKE. CURRENT MEDICATIONS
List any allergies applicant may have (include seasonal, food, medication etc).
INDEPENDENT LIVING SKILLS ABILITIES

Instructions: Please complete the skills screening using the scoring system outlined below. It is suggested that the screening be completed with the person who is being referred for residential support services in partnership with someone who knows the individual best.

Money Management
Food Management
Self-Care
Home Management
Safety
Health
Interpersonal and Coping Skills
Other
SUPERVISION NEEDED
SKILLS CHECKLIST
Financial Information
Income
Medical Insurance

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