*We recommend using Google Chrome to ensure proper functioning of this form. Resident Application Step 1 of 3 33% Today's Date(Required) MM slash DD slash YYYY Name of applicant:(Required) First Last Applicant's Date of Birth:(Required) MM slash DD slash YYYY About the ApplicantCurrent life situation:(Required)Reason for inquiry:(Required)Primary diagnosis:(Required)Diagnosed with developmental disability prior to age 21?(Required) Yes No If no, at what age?Seizures?(Required) Yes No If Yes, Please Describe:Current medications, dosage, and reasons for usage:(Required)Describe self-care skills and needs:(Required)Communications skills and needs:(Required)Relationships to others, social skills and needs:(Required)Describe level of sexual awareness:(Required)Relation to work: work interests, attitudes and habits, work tolerance, skills, and limitations:(Required)Awareness of date, time, place:(Required)Special interests, hobbies, and free-time activities:(Required)Idiosyncrasies, obsessions, fears:(Required)Tempers, outbursts, violence to self and/or others?(Required)Are there any forms of antisocial or aggressive behavior?(Required)Sense of danger?(Required)Able to read and write? Tell time? Use the telephone? Deal with money?(Required)General health and sleep habits:(Required)Relationship to pain and illness:(Required)Allergies?(Required) Yes No If yes, please describe:(Required)Special diet?(Required) Yes No If yes, please describe:(Required)Any special medical conditions we should know about?(Required)If you have anything more to add, please add it below.(Required)Type your name here as a digital signature:(Required) Address(Required) Street Address City State / Province / Region ZIP / Postal Code ContactTelephoneDaytime:Evening:CellEmail(Required) Relationship to Applicant:(Required)Please upload a photo of the applicant below.Accepted file types: jpg, jpeg, png, gif.CAPTCHA
