Admission Packet Access Page

Please enter the information below to begin the electronic admission packet. After this step, you will be directed to a private admission packet link for completion.

Please complete the packet as fully and accurately as possible. If you need to pause and return later, use the save options available inside the packet before closing your browser.

Resident First Name *

Resident Last Name *

Resident Date of Birth *

Applicant / Contact Email *

Applicant / Contact Phone

Relationship to Resident

Referral Source / Organization, if applicable

Requested Admission Date, if known

Short Reason for Admission Request

Packet Navigation

Complete each section carefully. Use Save Progress while working. If you may need to continue from another device, use Download Draft Backup before closing the packet. When finished, select Submit Completed Packet.

Packet ID

Resident Name

Resident Date of Birth

1. Resident Admission Application

Full Legal Name *

Preferred Name

Date of Birth *

Age

Gender Identity

Pronouns

Primary Language

Interpreter Needed?

Phone

Medicaid ID

Insurance ID

Current Address

Current Location

Reason for Admission Request *

Resident’s Own Goals

2. Guardian, Representative Payee, and Support Network

Applicant / Primary Contact

Contact Name

Relationship

Phone

May Contact?

Emergency Contact?

Guardian / Legally Responsible Person

Guardian/LRP Name

Relationship

Phone

Documentation Available?

Scope of Authority

Representative Payee

Payee Name/Organization

Contact Person

Phone

Benefits Managed

Documentation Available?

Support Network

Name	Relationship	Phone/Email	May Contact?	Emergency Contact?	Notes

4. Medical, Psychiatric, and Behavioral Health Profile

Diagnosis Type	Diagnosis	Source / Date	Notes
Primary Mental Health Diagnosis
Secondary Mental Health Diagnosis
Substance Use Diagnosis
Medical Diagnosis
Cognitive/Neurodevelopmental Diagnosis

Current Providers

Provider Type	Name/Organization	Phone	Email/Fax	Next Appointment
Primary Care
Psychiatric Provider
Therapist
Care Manager
Pharmacy

Recent Hospitalizations / Crisis Episodes

Pertinent Social, Family, and Medical History

5. Medication Intake and Pharmacy Information

Medication	Strength	Dose	Route	Frequency	Prescriber	Purpose

Preferred Pharmacy

Pharmacy Phone

Pharmacy Fax

Medication Allergies / Adverse Reactions

6. Safety, Behavior, Triggers, and De-escalation Profile

Area	Status	Details / Safety Plan Needed
Suicidal ideation / attempt history
Self-injury
Homicidal ideation/threats
Physical/verbal aggression
Property destruction
Fire-setting
Elopement/wandering
Substance use concerns
Medication refusal risk

Triggers

Early Warning Signs

Helpful De-escalation and Support Strategies

Safety Plan Notes

7. ADL, Mobility, Diet, and Routine Support

Activity	Support Level	Notes
Bathing/showering
Grooming
Dressing
Toileting
Medication routine
Appointment attendance
Community safety

Ambulates independently?

Uses cane/walker/wheelchair?

Fall history?

Requires stair-free access?

Special diet?

Food allergies?

Daily Routine Preferences / Health Support Details

8. Emergency, Service, and Information Release Consents

Emergency Contacts

Priority	Name	Relationship	Phone	May Receive Emergency Info?
1
2
3

I authorize A Place To Call Home Assisted Housing Communities LLC staff to contact emergency services, mobile crisis, law enforcement when required for safety, medical providers, emergency contacts, guardian/LRP if applicable, and other appropriate parties necessary to protect health and safety.

Consent to Services

I consent to admission and participation in supervised living services. I do not consent at this time. I need more information before consent can be completed.

Consent to Release / Exchange Information

Primary care provider Psychiatric provider Therapist/counselor Hospital/discharge planner LME-MCO/Tailored Plan/Medicaid Pharmacy Guardian/LRP Representative payee

Other Authorized Parties / Limitations

Authorization Expiration Date

9. Rights, House Guidelines, Transportation, and Medication Agreement

Rights Reviewed

Rights / Information Area	Reviewed	Resident/LRP Initials
Written summary of client rights provided
Right to dignity, respect, privacy, and confidentiality
Right to participate in service planning
Right to file a grievance without retaliation
House rules, fee practices, confidentiality, and emergency procedures reviewed

House Guidelines

Expectation	Initials
Treat residents, staff, visitors, and property with respect.
Follow the daily routine, meal schedule, medication routine, appointment schedule, and house safety expectations.
Do not threaten, harass, exploit, intimidate, or physically harm others.
Do not bring weapons, illegal substances, unauthorized medications, or unsafe items into the home.
Respect privacy and confidentiality of other residents.

Transportation Authorization

Medical appointments Behavioral health appointments Pharmacy Day program/PSR/clubhouse Benefits/legal appointments Family visits

Medication Support Agreement

Statement	Initials
I will provide current medication information and notify staff of medication changes.
I understand medications must be stored and handled according to facility policy unless self-administration is authorized.
I understand medications must not be shared, hidden, altered, discarded, or taken differently than prescribed.
I understand staff may contact prescribers/pharmacy regarding refills, orders, side effects, refusals, missed doses, or medication questions.

10. Personal Belongings and Property Inventory

Item Description	Quantity	Condition	Resident Initials	Staff Initials

11. Final Review and Electronic Signatures

Optional Photo/Media Consent

I consent to internal identification photo for resident record/safety purposes. I do not consent to internal identification photo unless required by policy/safety need. I consent to public marketing/photo/video use. I do not consent to public marketing/photo/video use.

Special Restrictions

Final Verification

Verification Item	Completed
Admission application complete
Required consents signed
Rights acknowledgment reviewed
Financial information completed to the best of applicant’s knowledge
Medication information completed to the best of applicant’s knowledge
Emergency contacts completed

Electronic signature acknowledgement: By typing your name, you are electronically signing this admission packet and confirming that the information is accurate to the best of your knowledge.

Resident Typed Signature *

Resident Signature Date *

Guardian/LRP Typed Signature, if applicable

Guardian/LRP Signature Date

Applicant / Person Completing Packet *

Relationship to Resident

Final Comments / Information A Place To Call Home Should Know

Submission does not guarantee admission. A Place To Call Home will review the packet for clinical appropriateness, safety, funding readiness, and program fit.

A Place To Call Home Assisted Housing Communities LLC

Admission Packet Access Page

Private Packet Link Required

Packet Navigation

1. Resident Admission Application

2. Guardian, Representative Payee, and Support Network

Applicant / Primary Contact

Guardian / Legally Responsible Person

Representative Payee

Support Network

3. Financial and Benefits Profile

Current or Anticipated Funding Source

4. Medical, Psychiatric, and Behavioral Health Profile

Current Providers

5. Medication Intake and Pharmacy Information

6. Safety, Behavior, Triggers, and De-escalation Profile

7. ADL, Mobility, Diet, and Routine Support

8. Emergency, Service, and Information Release Consents

Emergency Contacts

Consent to Services

Consent to Release / Exchange Information

9. Rights, House Guidelines, Transportation, and Medication Agreement

Rights Reviewed

House Guidelines

Transportation Authorization

Medication Support Agreement

10. Personal Belongings and Property Inventory

11. Final Review and Electronic Signatures

Optional Photo/Media Consent

Final Verification