Placement Application Step 1 of 5 20% Personal InformationName First Last Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone #Cell Phone #Email* Desired Move in Date or Timeline?*Guardianship Type*SelfPrivatePublicMarital Status*Unmarried/SingleMarriedLanguage(s) Spoken*Religious PreferenceOther Information Identifying CharacteristicsGenderRaceWeightHeightHair ColorEye ColorDistinguishing characteristics/identifying marks Medical InformationDiagnosesAllergiesProtocols (seizure, diabetic, etc.)Does the person have a Do Not Resuscitate (DNR), Do Not Intubate (DNI) or other advanced care directive? Yes No If "Yes", describeDoes this person smoke? Yes No If "Yes", how much?Type of service desired Supported Living Services (SLS) in a community residential setting Board and Lodge Individualized Home Supports (IHS) in your own home or setting outside of The Cottages. Other Medical equipment, devices, or adaptive aides or technology usedSpecialized dietary needsPlease attach a current and complete medication listMax. file size: 300 MB.Please attach a current care plan, CSSP, CSSPA or other documents you feel would be necessary in determining whether or not this individual would be a good fit.Max. file size: 300 MB.Has applicant ever been prescribed a psychotropic medication? Yes No Will applicant accurately report illness or injury? Yes No Does applicant cooperate with health care providers or medical treatments? Yes No General Daily Living InformationDoes the applicant make their own financial decisions? Yes No Will The Cottages be responsible to help manage any/all finances? Yes No Is the applicant vulnerable to financial exploitation? Yes No Describe applicant’s ability to assess personal and community safety, areas of vulnerability, etc.Applicant’s typical Community Alone TimeMissing Time LimitDoes the applicant need assistance with ADL’s? Yes No If yes, please list:Is there anything else we should know about this applicant? General Contact InformationLegal RepresentativeName, Phone #, AddressAuthorized RepresentativeName, Phone #, AddressPrimary Emergency ContactName, Phone #, AddressCase ManagerName, Phone #, AddressFamily MemberName, Phone #, AddressFamily MemberName, Phone #, AddressOtherName, Phone #, AddressFinancial WorkerName, Phone #, AddressResidential ContactName, Phone #, AddressVocational ContactName, Phone #, AddressOther Service ProviderName, Phone #, AddressSignature Southern MN: 14/15 Beds 1 opening
