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Location

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Caring Hands Refferal

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- Step 1 of 10

APPLICANT’S GENERAL INFORMATION

Name *

Date of Birth

Place of Birth

Current Address

Address Line 1

City

State

Zip Code

Permanent Address

Address Line 1

City

State

Zip Code

Where do you live ?

Telephone

Social Security

Type of Income/Amount

Medical Assistance

Medicare

Other Health Insurance

Prescription Coverage

Does Applicant have a Service Coordinator?

Name *

Phone

PARENT/GUARDIAN/CAREGIVER INFORMATION

Name *

Relationship to Applicant

Address

Address Line 1

City

State

Zip Code

Phone Number

Cell Phone Number

Email *

May we send you information via e-mail? *

home Home dental

Parents

Guardian or Relatives

Foster Home

Other

Address

Phone Number

Legal Guardian

Date Guardianship was attained

Number of occupants living in the home

Type of Guardianship

Full
Property
Limited
Medical
Person

Name *

Date

Address

Occupation

Work Phone

Work Address

Social Security #

Living/Deceased If deceased, date

Place of Birth

Name *

Date

Address *

Home Phone *

Occupation *

Work Phone *

Work Address *

Social Security # *

Living/Deceased If deceased, date: *

Place of Birth *

Date

Marital Status *

Name *

Relationship to applicant

Address

Phone Number

SSI Claim

SSI Amount

SSA Claim

SSA Amount

Name of wage earner

Name of Representative Payee

V.A. Claim

V.A. Benefit Amount

Name of Veteran

Railroad Retirement Claim Number

Name of Wage earner

Life Insurance Coverage

Burial Plot location

Estimated value

Type of Burial Plan

Other sources of Applicant’s Income

Applicant’s Bank Account

Any property in applicant’s name (give location and value)

Trust Fund:

YES
NO

TYPE

If yes, give name and address of trustee

Applicant’s place of employment (name and address)

Applicant’s monthly earnings from employment

Applicant’s primary health care provider/physician

Address

Phone Number

Examined by

Address

Primary

Diagnosis

Primary

Secondary

Tertiary

Age of Onset

Seizures

Does the applicant have seizures?

Yes
No

Frequency

Daily
Weekly
At least once a month
Every few months

Type of seizures

Are seizures controlled by medication?

Yes
No

Applicant’s Mobility

Walks independently
Uses cane
Uses crutches
Uses walker
Uses wheelchair
Yes
No
Manual
Electric
Self propelled

Vision

Any vision impairment:

Yes
No

Does applicant wear glasses or contact lenses?

Date of last eye exam

Legally Blind

Yes
No

Hearing

Does applicant have a hearing problem?

Yes
No

Date of last hearing exam

Deaf

Yes
No

Dental

Date of last hearing exam

Dentures

Yes
No

Brief description of any dental problem(s)

Equipment Needed

Hoyer Lift
Bed Rails
Need for oxygen?
Other adaptive / special equipment

Allergies(bee stings, drugs, dust, mold, food, etc.)

Does applicant have any other medical problems not listed?

Diet (chopped food, tube fed, finger foods etc.)

Does applicant have a speech / language impairment:

Yes
No

Is applicant verbal?

Yes
No

Has applicant had a speech/language assessment?

Yes
No

Type of assistance needed with toileting

Has applicant had a speech/language assessment?

Speech
Sign Language
Gestures
Communication Board

Is applicant independent in personal self-care skills?

YES
NO

Assessment done by

Does (s)he prefer a bath or a shower?

Can applicant self medicate?

YES
NO

Can applicant cross streets?

Independently
With Assistance
NO

Can applicant use mass transit?

Independently
With Assistance
NO

Is applicant capable of remaining at home unsupervised?

YES
NO

IF YES, How Long ?

Can applicant read?

YES
NO

Does applicant sleep through the night?

YES
NO

What time does the applicant usually go to bed?

What time does the applicant get up in the morning?

What does the applicant like to do in his/her free time?

Please provide a brief description of the applicant’s daily routine

Signature File

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Caring Hands, Inc. is dedicated to delivering compassionate, inclusive, and holistic care that empowers individuals to live with dignity, independence, and purpose.

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410-461-2814
2027 Suffolk Road Suite 1
Finksburg,MD 21048

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