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 ______