Caring Hands Inc. Application – English

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info@caringhandsinc.org
410-461-2814

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Caring Hand Referral
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Home
About
Caring Hand Referral
Services
Resources
Location
Staff Portal

Home
About
Caring Hand Referral
Services
Resources
Location
Staff Portal

Home
About
Caring Hand Referral
Services
Resources
Location
Staff Portal

Home
About
Caring Hand Referral
Services
Resources
Location
Staff Portal

Home
About
Caring Hand Referral
Services
Resources
Location
Staff Portal

Caring Hands Refferal

Apply Now

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Name *

Place of Birth

Where do you live ?

Social Security

Medical Assistance

Other Health Insurance

Type of Income/Amount

Medicare

Prescription Coverage

Name *

Relationship to Applicant

Email *

May we send you information via e-mail? *

Parents

Foster Home

Address

Legal Guardian

Guardian or Relatives

Other

Phone Number

Date Guardianship was attained

Number of occupants living in the home

Type of Guardianship

Full
Property
Limited
Medical
Person

Name *

Address

Work Phone

Social Security #

Occupation

Work Address

Living/Deceased If deceased, date

Name *

Address *

Occupation *

Work Address *

Living/Deceased If deceased, date: *

Home Phone *

Work Phone *

Social Security # *

Place of Birth *

Marital Status *

Name *

Address

Relationship to applicant

Phone Number

SSI Claim

SSA Claim

Name of wage earner

V.A. Claim

Name of Veteran

Name of Wage earner

Burial Plot location

Type of Burial Plan

Applicant’s Bank Account

SSI Amount

SSA Amount

Name of Representative Payee

V.A. Benefit Amount

Railroad Retirement Claim Number

Life Insurance Coverage

Estimated value

Other sources of Applicant’s Income

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

Address

Examined by

Primary

Phone Number

Address

Primary

Tertiary

Secondary

Age of Onset

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

Any vision impairment:

Yes
No

Does applicant wear glasses or contact lenses?

Date of last eye exam

Legally Blind

Yes
No

Does applicant have a hearing problem?

Yes
No

Date of last hearing exam

Deaf

Yes
No

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

Claim Cell

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

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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About
Caring Hand Referral
Services
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Location
Staff Portal

CONTACT INFO

info@caringhandsinc.org
410-461-2814
2027 Suffolk Road Suite 1
Finksburg,MD 21048