Personal Care Intake Packet — Full Assisted Living

1

1. Applicant Information

Resident Full Name*

Preferred Name / Nickname

Date of Birth*

Gender

Phone

Email

Current Address

Primary Language

Veteran Status

YesNo

2

2. Emergency Contacts

Primary Contact

Name*

Relationship

Phone*

Alternate Phone

Email

Secondary Contact

Name

Relationship

Phone

Alternate Phone

Email

3

3. Responsible Party / POA Information

Name

Relationship

Phone

Email

Address

Legal Authority (check all that apply)

Power of Attorney (attach copy)Guardian (attach court order)Health Care ProxyOther

If Other, specify

4

4. Medical Information

Primary Care Physician

Physician Phone

Physician Fax

Preferred Hospital

Diagnoses

Attach physician documentation if available

Allergies

No known allergies

Medication allergy

Food allergy

Environmental allergy

Current Medications

Attach MAR if available

Pharmacy Name

Pharmacy Phone

5

5. Functional Assessment (ADLs & IADLs)

Activities of Daily Living (ADLs)

Bathing / Showering

Dressing / Undressing

Grooming / Hygiene

Toileting

Continence

Eating / Feeding

Transfers (bed/chair)

Ambulation / Walking

Instrumental ADLs (IADLs)

Meal Preparation

Housekeeping

Laundry

Medication Management

Transportation

Managing Finances

Using Phone / Technology

6

6. Cognitive & Behavioral Assessment

7

7. Service Needs Checklist

The resident is requesting the following services (check all that apply):

Other services needed

8

8. Financial Information

If Other, specify

Responsible Party for Billing

Social Security Income

Pension Income

Other Income

9

9. Consent & Authorization

By submitting this form, you authorize 4Ever Health Care, Inc. to use the information provided to develop a personalized care plan and coordinate services. All information is kept strictly confidential in accordance with applicable Pennsylvania privacy laws.

A. Consent for Care

I authorize the facility to provide personal care services, supervision, and assistance as outlined in my service plan.

Authorized By (Print Name)*

Date*

B. Medication Administration Consent

I authorize the facility to administer medications as prescribed.

Authorized By (Print Name)

Date

C. Release of Medical Information

I authorize the release of medical information to the facility for care coordination.

Authorized By (Print Name)

Date

D. Photo / Media Consent

Yes — consent to photos for internal useNo — do not consent

Authorized By (Print Name)

Date

10

10. Resident Rights Acknowledgment

I acknowledge receipt of the Resident Rights & Responsibilities document.

Acknowledged By (Print Name)*

Date*

11

11. Move-In Checklist

12

12. Facility Policies Acknowledgment

Resident/Representative acknowledges receipt of the following policies:

Authorized By (Print Name)*

Date*