Please Print and mail:

CHATHAM COUNTY GROUP HOMES, INC

APPLICATION FOR READD CENTER & COMMUNITY SUPPORTS

 

 

I.          IDENTIFYING INFORMATION

Name:    ____________________________________________________________________________

Address: __________________________________________________________________________________

Telephone:  ___________________                         Social Security Number:     _________________________

Birth date:   __________________                         Birth place:     __________________________

Legal County of residence:  __________________________________________

Guardian/ Parent Name:     __________________________________________________________________

Address:  ______________________________________________________________________________

Phone: Home:     ________________________                 Work:   ______________________________

Can you provide proof of guardianship?  ___Yes   _____No

List Members of immediate family:

Name, Address, Phone and relationship:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________

Physician name, address, phone:   _______________________________________________________________

Dentist name, address, phone:     _________________________________________________________________

 

II.        REASON FOR ADMISSION:

   _______________________________________________________________________________________________

 ________________________________________________________________________________________________

 ________________________________________________________________________________________________

Are you requesting placement for READD Center (day program)? ___ Yes  ___ No

Are you requesting service for Home/Community Support?  ___Yes  ___ No

III.       HISTORY

Education

Schools Attended:   ________________________________________________________________________________

Previous Job History:     _____________________________________________________________________________

    _____________________________________________________________________________________________

 

IV.       SOCIAL

1.      Does applicant want to live in group home?    _____________

2.      What are the interest and hobbies of applicant?     _________________________________________________________

3.      How does applicant spend most of their time now?     _______________________________________________________

_____________________________________________________________________________________________

 

V.           PHYSICAL CAPABILITIES

Does applicant have problems with any of the following?  Check all that apply

___Speech   ___Vision  ___ Hearing  ___ Walking  ___ Running  ___ Standing  ___Use of hands

 

ABILITIES

Check one of the following that apply:

FUNCTION    WITHOUT ASSISTANCE     WITH ASSISTANCE             NOT AT ALL

Bathe                         ___                                          ___                                          ___

Brush Teeth              ___                                          ___                                          ___

Comb Hair                ___                                          ___                                          ___

Dress Self                  ___                                          ___                                          ___

Tie Shoes                    ___                                          ___                                          ___

Feed Self                    ___                                           ___                                           ___

Shave                          ___                                          ___                                           ___

Menstrual Hygiene    ___                                          ___                                           ___

Make Bed                    ___                                           ___                                          ___

Clean Room               ___                                           ___                                           ___

Care for Clothing       ___                                           ___                                           ___

Care for personal items    ___                                    ___                                            ___

Use bathroom             ___                                          ___                                           ___

 

VII.   MEDICAL

  1. Diagnosis:  ___________________________________________________________________________________

 

  1. List hospitalizations within last five (5) years.  Include reason, date and place:

   _______________________________________________________________________________________________

   ______________________________________________________________________________________________

     _______________________________________________________________________________________________

     _______________________________________________________________________________________________

3.  Date of last physical exam and name of doctor: _____________________________________________________

4.  Does applicant take medications for any on-going problems:  If so, please give: Medication, Dosage, Reason for taking

____________________________________________________________________________________________

____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

5.  List any allergies:    __________________________________________________________________________

6.  Does applicant require special diet?  Yes   No  If yes, please specify diet:   ____________________________________

 

VIII.  MENTAL CAPABILITIES

1.  Can applicant follow directions for three step command and respond correctly?___Yes ___ No

2.  Aware of place and time? ___  Yes ___  No

3.  Sign own name? ___  Yes  ___ No

4.  Is there any unusual or peculiar behaviors? ___ Yes  ___ No  If yes, please explain:   ___________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

5.  Any self abusive behaviors?   ___Yes ___  No  Please explain:  ___________________________________________

_________________________________________________________________________________________________

________________________________________________________________________________________________

6.  Violent or destructive towards others or property?  ___ Yes  ___ No  Please explain:  ___________________________

_________________________________________________________________________________________________

7.  Has applicant had treatment by psychiatrist, state hospital, mental retardation center or mental health

center?  __ Yes  _ No    Please explain:   __________        ______________________________________________

________________________________________________________________________________________________

IX.  FINANCIAL RESOURCES

      1. Income: ____________________________________________________________________________

Does applicant currently receive CAP services? If so,  please give support name and contact number:  ______________________

________________________________________________________________________________________________

X.  GENERAL

      1. Please place a check in front of all the following test and immunizations applicant has had and the last year they were received:

 

Check

Year

Test

Physical Exam
Chest X-Ray
TB Skin Test

Check

Year

Immunization

Tetanus Shot
DPT
Hepatitis B
Flu
Polio

 

 

 

 

      1. Please list food likes and dislikes:    ___________________________________________________________

 _________________________________________________________________________________________________

 

      1. Please give any information not already given, that my be helpful:     _________________________________

________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

 

 

 

CERTIFICATION

I certify that all information on this application is accurate and complete in the areas of behavioral problems, sexual problems, physical capabilities, psychological difficulties and finances to the best of my knowledge.

 

Guardian or applicant signature: ______________________________      Date:  _____________________

 

 

Please return application to:

Chatham County Group Homes, Inc

PO Box 207

Siler City   NC  27344