The Chapman House
(207)783-0961
Please fill out this application and return it with your completed financial statement to be placed on the waiting list at The Chapman House. An application and assessment of care needs must be completed and approved prior to residency.
Resident Profile
Today’s date ______
Person filling out application ______Relationship ______
Name______Birth Date ______
Address______
Telephone______Former Occupation ______
Marital Status single married widowed divorced separated
Primary Language ______Religion ______
Social Security Number ______Medicare Number ______
Maine Care Number ______Other insurance ______
Current Living Arrangements
In own home Apartment Boarding home Hospital
Living w/ relative or friend Other ______
Responsible Person in an Emergency
Name ______Relationship ______
Address______
Telephone ______Cell ______
Does this person have Power of Attorney Guardianship
Does this applicant have a Living Will Yes No
Family and/or significant others
Name ______Relationship ______
Address ______
Telephone ______Work ______Cell ______
Name ______Relationship ______
Address ______
Telephone ______Work ______Cell ______
Primary Physician
Name ______
Address ______
Telephone ______
Dental, Vision, Hearing, and Assistive Devices (check if applicable)
Eyeglasses Hearing Aid Dentures Cane Walker
Activities of Daily Living
Independent Needs Supervision Needs Assistance
If you are on a special diet, please describe it briefly here:
______
Special Care Needs (balance, memory concerns, incontinence, diabetic)
______
Falls
Yes No If yes, how often in the past year? ______
Has the applicant had a Goold assessment done?
Yes No
Tobacco use Alcohol use
Yes No Yes No
Preferred Pharmacy ______
Preferred Hospital ______
If someone other than you administers your finances, please provide this information:
Name ______Telephone ______
Address ______
If Applicable has all Maine Care forms and paperwork completed?
Yes No Date completed ______
Income
Social Security, SSI, Pensions $ ______
Interest, Dividends $ ______
Other Income $ ______
Assets
Bank Accounts $ ______
CDs $ ______
Investments $ ______
Real Estate $ ______
Authorization
I declare the information in this application is true and complete. I also give The Chapman House permission to secure a medical report from the physician listed above.
Signature of resident or POA ______Date ______
Physician Copy (please sign in addition to previous page)
Physician ______
Authorization
I declare the information in this application is true and complete. I also give The Chapman House permission to secure a medical report from the physician listed above.
Signature of resident or POA ______Date ______