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Assessment Request Form
Applicant's Full Name:
Birth Date:
Gender:
Male
Female
Applicant Full Address:
Subject:
Marital Status:
---
Married
Single
Separated
Widowed
Divorced
Present Living Arrangements:
---
With Relative
With Non-Relatives
Alone(House or Apartment)
Along(Single Room)
Divorced
Medicaid #:
Medicaire #:
Supplemental Security Income #:
Tell us why you are interested in joining this program?:
Have you had previous experience in an Adult Day Care Program?:
Yes
No
If yes, where and when?:
Living with whom:
Relationship with whom their living:
Nearest Responsible Relative:
Relationship to Nearest Relative:
If Employed, Where:
Business Phone:
Emergency Contact #1:
Relationship Applicant:
Emergency Address#1:
Emergency Phone:
Emergency Contact #2:
Relationship Applicant:
Emergency Address#2:
Emergency Phone:
Physician Information:
Physician Address:
Physician Phone:
Physician Visit Date:
Dentist Name:
Dentist Address:
Dentist Phone:
Dentist Last Visit Date:
Transportation will be Provided by:
---
Relative or Friend
Public Transportation
Blessed Assurance
Arrive Time:
Departure Time:
Special Diet?:
Yes
No
If yes, give details below:
List all Food and/or Drug Allergies:
Days and Times Requested to be at Blessed Assurance:
I acknowledge that the participation in this program will be paid by:
---
Myself
Relative(Give Name Below)
Another Party(give name below)
Give Name of Person/Party Responsible that is Mentioned above:
Phone Number of Person to Pay Bill:
Your Email:
If emergency medical care becomes necessary, I give permission for any treatment the physician deems necessary. My hospital choice is:
but I (the applicant) may be treated at the nearest facility if the emergency deems it necessary.
By entering your full name below you are digitally signing this form. Please enter your full name:
Today Date:
Submit