CHATHAM COUNTY GROUP HOMES, INC

APPLICATION FOR GROUP HOME ADMISSION

 

Please print and return application to: CCGH, Inc.    PO Box 207  Siler City   NC  27344

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

Physician name, address, phone:  _______________________________________________________

Dentist name, address, phone:    ___________________________________________________________

Church Affiliation:   ______________________________________

 

II.        REASON FOR ADMISSION:

  _________________________________________________________________________________________

__________________________________________________________________________________________

___________________________________________________________________________________________

III.             HISTORY

Education

Schools Attended:  ____________________________________________________________________________

 

Previous Job History:     _________________________________________________________________________

  _________________________________________________________________________________________

IV.       SOCIAL

1.      How often does applicant see family?    _____________________________________________________

2.      Does applicant want to live in group home?   __________

3.      We encourage family contact and ongoing relationships.  Applicant will be allowed one weekend a month and vacations at Thanksgiving, Christmas and a week at July 4th.  Who will applicant spend this time with?   ________________________

4.      Does family plan on future involvement with client in addition to vacations?___ Yes  ___ No

5.  What are the interest and hobbies of applicant?    _______________________________________________________

_____________________________________________________________________________________________

6.  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:

  _________________________________________________________________________________

    _________________________________________________________________________________

     ________________________________________________________________________________

     ________________________________________________________________________________


  1. Date of last physical exam and name of doctor: __________________________________________________
  2. Does applicant take medications for any on-going problems:  If so, please give:

Medication, dosage, frequency, reason for taking: ________________________________________________________

Medication, dosage, frequency, reason for taking: ________________________________________________________

Medication, dosage, frequency, reason for taking: ________________________________________________________

Medication, dosage, frequency, reason for taking: ________________________________________________________

Medication, dosage, frequency, reason for taking: ________________________________________________________

 

  1. List any allergies:   ___________________________________________________________________________

 

  1. Does applicant require special diet?  __Yes  __No  If yes, please specify diet:  __________________________________

 

  1. Date of last dental exam and condition of teeth and gums:   _______________________________________________

 

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:   _____________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

  1. Any self abusive behaviors?   Yes   No  Please explain:   _________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

  1. Violent or destructive towards others or property?   Yes   No  Please explain:    _________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

  1. Has applicant had treatment by psychiatrist, state hospital, mental retardation center or mental health center?   Yes   No    Please explain:      ____________________________________________________________________________

__________________________________________________________________________________________

IX.  FINANCIAL RESOURCES

  1. Income:
    1. Does applicant currently receive CAP services? If so,  please give support name and contact number:  __ ____    _ ____
    2. SSI Amount  _____
    3. SSA Amount:  _____
    4. Other:  _______________________________________________________________________

 

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

 

 

 

2.  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:  __________________________