Building and Restoring Hope, Inc.dba: Adult Day Care & Day Activity

Physical: 12805 Cullen Blvd-Building B Unit G1 Houston, Texas 77047

Mailing: PO Box 331476 Houston, Texas 77233

E: W:

(832-577-4984) PH (281) 501-1276 FX

Family and Personal Information

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Full Name / :
Address / :
Telephone Number / :
Date of Birth / : / (dd/mm/yy) Age:______Social Security #______-___-_____
Place of Birth / :
Marital Status/Race / : / Married Single Divorced Widowed □Caucasian □African American□ Hispanic/Latino □Other

Medicaid

#:WE DO NOT ACCEPT MEDICARE! NO MQB!!!!

What Managed Care Plan? (Amerigroup, Molina or United Healthcare)

#:

Other insurance coverage:

Name of husband or wife, if living / :
With whom does applicant live? Specify if Care Home / :
Name and address of next nearest relative or trusted friend who could be contacted in an emergency:
Name / Address / Telephone Number
Work / Home

Health History

List any major operations or chronic illnesses or conditions you have experienced.

***** LIST ALL MEDICATIONS!!!

Current Medications: / Dosage: / Times Given:

Does client smoke? ______Yes ______No

****Name, Address and telephone number of physician(s):

Physician / Address / Telephone

Choice of hospital:

Pharmacy Name:Telephone:

What assistance (if any) is required in the following areas?

Area / None / Other / Explain
a. / Walking, Standing
b. / Toileting
c. / Bathing
d. / Eating

Dietary Requirements:

a. / Regular diet /
b. / Low sodium /
c. / Diabetic /
d. / Other

Is supervision required?
YesNoExplain (if yes)

Requested Starting Date: Frequency:

Days: MondayTuesday WednesdayThursdayFriday

Transported by:MetroFamilyOther

Assistance required:

What special needs does the applicant have? (i.e., Need for socialization, supervision, etc)

*****Name, Address and telephone number of individual or agency responsible for payment of Adult Day Care services:

Name / Address / Telephone

****PLEASE BE AWARE THAT YOU AS A CAREGIVER CAN BE HELD RESPONSIBLE FOR THE PAYMENT OF THE INDIVIDUAL ATTENDING ADULT DAY CARE IF HE/SHE ATTENDS AND THEY DO NOT HAVE MEDICAID.*****

I, as caregiver, agree/do not agree to provide transportation to the BRH Adult Day Center.

Signature of Responsible Party:
Date:

Received By: ______

******PLEASE SEND: COPIES NEEDED ASAP:

  1. MEDICAID CARD (Current)
  2. CURRENT IDENTIFICATION (Clients CANNOT visit Adult Day Care Physician if no ID)
  3. SOCIAL SECURITY CARD (IF THEY HAVE)Bottom of Form

Building and Restoring Hope, Inc. follows federal, state, and local law to ensure equal recruitment, employment, compensation, development and advancement opportunity for all qualified individuals, and prohibits deliberate harassment based on federally protected categories of race, color, religion, sex, national origin, age, or disability.

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