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Shangri-La Care Home
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GALLERY
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RESIDENT INTAKE FORM
First name
*
Last name
*
Phone
*
Email
*
Name of Resident
*
Relation to Resident
*
Resident Age
*
Gender
*
Weight
*
Height
*
Do you already have an RN Assessment?
*
Yes
No
How did you hear about us?
*
For Other, please specify.
Relevant medical history (With dates/year, if known)
*
Reason for moving into an Adult Family Home
*
Eating
*
Personal Hygiene
*
Mobility
*
Transferring
*
Bathing
*
Toileting
*
Memory Issues
*
Medication Assistance
*
Behavior
*
Skin Condition
*
Other information you want us to know
Current Living Situation
*
Funding Source
*
Private Pay
Medicaid on Admission
Medicaid Spend Down
Others
For Medicaid Spend Down, what is the estimated number of months prior to Medicaid conversion.
Target Move In Date
*
Month
Month
Day
Year
Would you like a summary of disclosures of our rates and services, including itemized services?
*
Yes
No
Any questions for us?
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ABOUT
SERVICES
INTAKE FORM
GALLERY
SOCIAL
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