RAY OF HOPE LIVING, LLC

540)376-7638 (Office) - (540)693-4091 (Fax)

APPLICATION FOR ADMISSION
General Information
Name:
___________________________________

DOB:

Current Address:

City/State

Place of Birth:

___________________________________

______________________, ________

_________________, _______

Citizenship Status:

Marital Status (Check one)

Phone: (H)___________________________
(C)___________________________

USA:

Other:______________________

Other:________________________

SSN:
________ - _____ - ________

Married Divorced
Single
Separated
Widowed

Language Spoken or Understood:

Religious Preference:

Identifying Marks:

_______________________________

________________________________

_________________________

Medical Insurance Company:

Policy/Member Number:

Group Number:

_______________________________

_______________________________

Medicaid Number:

Medicare Number:

_________________________
_
Medicaid Waiver:

_____________________________________

_______________________________

Height:____________________

Hair Color:________________

Weight:____________________

Eye Color: ________________

Emergency/Guardian Contact
Name:

Address:

______________________________________

__________________________________________________________

Phone: : (H)___________________________

Yes

No

__________________________________________________________

(C)___________________________

__________________________________________________________

Other:__________________________

Relationship to Individual:____________________________________

Family Contacts
Name:

Address:

______________________________________

__________________________________________________________

ROH Admission Application

Phone: (H)___________________________
__________________________________________________________
(C)___________________________
Other:__________________________

__________________________________________________________

Name:

Relationship to Individual:____________________________________
Address:

_____________________________________

__________________________________________________________

Phone:

__________________________________________________________

(H)___________________________
(C)___________________________
Other:__________________________

__________________________________________________________
Relationship to Individual:____________________________________

Physician Information
Name:

Address:

_____________________________________

__________________________________________________________

Phone:

(O)___________________________

__________________________________________________________

(F)___________________________
__________________________________________________________
Medical History/Status
Description of General Health:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
List of Medications:
Last Physical (Date): _______/______/________
____________________________________________________________
Allergies:_____________________________________
____________________________________________________________
_____________________________________________
____________________________________________________________
_____________________________________________
____________________________________________________________
_____________________________________________
____________________________________________________________
_____________________________________________
____________________________________________________________
_____________________________________________
_____________________________________________

ROH Admission Application

____________________________________________________________
__
2

Medical History/Status (cont.)

Recent Complaints/Problems:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Last Serious Illness:(List)__________________________________________________ (Date)___________________________
Infectious Disease:(List)__________________________________________________ (Date)___________________________
Injury:(List)__________________________________________________ (Date)___________________________
Hospitalizations:(Name)__________________________________(Why)________________________ (Date)________________
(Name)__________________________________(Why)_____________________________________ (Date)________________
(Name)__________________________________(Why)_____________________________________ (Date)________________
(Name)__________________________________(Why)_____________________________________ (Date)________________
Family History of Medical or Mental Illnesses:
(Name)__________________________________(Relationship)__________________ (Dx)______________________________
(Name)__________________________________ (Relationship)__________________ (Dx)______________________________
(Name)__________________________________ (Relationship)__________________ (Dx)______________________________
(Name)__________________________________ (Relationship)__________________ (Dx)______________________________
Substance/Alcohol Abuse History:

Yes

No

(If Yes List)_______________________________________

_________________________________________________
_________________________________________________
_________________________________________________
________________________________________________

ROH Admission Application

Orally Gestures In Writing Reads

Consumes Foods: Independently Some Support Needed
Total Support Needed
Mobility: Independently Some Support Needed
Total Support Needed Wheelchair Walker
Bathing: Prefers Shower Tub Independently
Some Support Needed Total Support Needed
Dressing/Undressing: Independently Some Support Needed
Total Support Needed
Brushing Teeth: Independently Some Support Needed
Total Support Needed
Communicates:

Menstrual Hygiene (women):

Independently Some Support

Total Support Needed

Shaving (men): Independently Some Support Needed
Needed

Total Support Needed

Condition

Client

Mother

Father

Sibling

Sibling

Sibling

Alcoholism

Allergies

Anemia

Arthritis

Asthma

Cancer

Diabetes

Hearing Problems

Heart Disease

Hypertension

Kidney Disease

Obesity

Sickle Cell Anemia

Smoker

Substance Abuse

Tuberculosis

Ulcers

Vision Problems

Social/Developmental Summary
Father:
Mother:
Sibling:

ROH Admission Application

Living
Living

Deceased
Deceased

Living

Deceased
4

Sibling:

Living

Deceased

Sibling:

Living

Deceased

Sibling:

Living

Deceased

Give description of development and when maturational milestones were met:

__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Educational Background
College:

City, State:

___________________________________________________

Diploma?

Yes No

Major:_____________________________________

________________________,__________

High School:

City, State:

Year:________
Diploma?

Yes No
___________________________________________________

________________________,__________

Middle School:

City, State:

Year:________
Diploma?

Yes No
___________________________________________________

________________________,__________

Elementary School:

City, State:

___________________________________________________

________________________,__________

Year:________
Diploma?

Yes No
Year:________

Vocational/Other Training
School Name:

City, State:

Diploma?

___________________________________________________

________________________,__________

Yes No
Year:_______

ROH Admission Application

Employment History
Employer Name:

Location:

__________________________________________________

__________________________________________________
__________________________________________________

Telephone:

How Long Worked?

(_______) ________________- _________________

_________________

Employer Name:

Location:

__________________________________________________

__________________________________________________
__________________________________________________

Telephone:

How Long Worked?

(_______) ________________- _________________

_________________

Employer Name:

Location:

__________________________________________________

__________________________________________________
__________________________________________________

Telephone:

How Long Worked?

(_______) ________________- _________________

_________________

Independent Living Skills

Grooming:

Dressing:

Independently Some Support Needed Total Support Needed Independently Some Support Needed Total Support
Needed
Bathing:

Toileting:

Independently Some Support Needed Total Support Needed Independently Some Support Needed Total Support Needed
Household Chores:

Cooking:

Independently Some Support Needed Total Support Needed Independently Some Support Needed Total Support Needed
Laundry:

Room Maintenance:

Independently Some Support Needed Total Support Needed Independently Some Support Needed Total Support Needed
Community Outing:

Leisure Activity:

Independently Some Support Needed Total Support Needed Independently Some Support Needed Total Support Needed

ROH Admission Application

Behavior: Self-Injurious Behavior

Temper Outbursts Responds

Threatens or Does Physical Violence to Others Throws Things Destroys Property

in a Socially Unacceptable Manner

Responds to verbal prompts to change behavior (Cues needed

__)

Financial Information

Income Amount (Monthly): $__________________

Source(s) Employment

SSI SSDI Food Stamps

Other______________
Housing
Previous Placement(s)

Address:

Name:__________________________________________________

_________________________________________________

_______________________________________________________

_________________________________________________

Phone: ( _____) ____________-_____________

Dates:_________________________________
Address:

Name:__________________________________________________
_______________________________________________________
Phone: ( _____) ____________-______________

_______________________________________________
_______________________________________________
Dates:_________________________________
Address:

Name:__________________________________________________
_______________________________________________________
Phone: ( _____) ____________-______________

_______________________________________________
_______________________________________________
Dates:_________________________________

The contents of the preceding application are true and correct to the best of my (our) recollection.
_____________________________________________
Applicant Signature
________________________________________________
ID Coordinator/Case Manager/Person Signature

_____________________________________________
Guardian/Authorized Representative
________________________________________________
ROHL, LLC Program Coordinator/Designee Signature

Please attach the most recent copy of the individuals Person Centered Plan Parts 1 through 5, Completed
Release of Information, Photo ID, Copies of Medical Insurance Cards, Guardianship/Authorized
Representative Documentation and Most recent Physical Examination.
Updated 9/10/15 alm

ROH Admission Application