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Consent Form

Generated with MOOJ Proforms Basic 1.1
* Required information.
CONTACT INFORMATION: FAMILY
First Name *
Last Name
Date
Address *
City *
State *
Zip Code *
Home Phone *
Mobile Phone
Email Address *
Emergency Contact Phone *
Name of Legally Responsible Person *
CONTACT INFORMATION: RESIDENT
Resident First Name
Resident Last Name
Resident Date of Birth
Resident Age
Resident Weight
Resident Height
Facility Name
Facility Address
Facility City
Facility State
Facility Zip
Facility Phone
Name of Company running facility
Facility Director's Name
Director's Phone
Director's Mobile
MEDICAL
Medical History
Medical History 2
Medical History 3
Medications
Allergies
Special Equipment Required
Critical Supplies
Other supplies required
Residents Emotional State
Have there been any incidents with resident?
Are there existing accident reports?
If so, how many?
Does resident have access to alcohol?
Does resident smoke?
Does resident have access to non-prescription medications?
If so, what type and how often?
Is the resident disabled?
If so, what is the disability?
Who is the residents insurer?
Physical condition/capabilities?
Residents Limitations?
Most critical needs
Who is responsible for medical records?
Primary Doctor's Name?
Where are the records kept?
Is the resident capable of dressing themselves?
Can they use the bathroom unattended?
Are there any existing physical impairments?
Are there any existing marks or scars cuts, burns etc?
If so, where are they located?
FINANCIAL:
Legal financial party
who is responsible for residents finances?
Does resident utilize their own finances?
If so, how often?
How much and on what items?
Does resident keep cash on hand?
Does resident keep credit cards?
If so, who receives the statement?
Does resident have personal property at facility?
If so list of items?
Does the resident possess valuables at facility such as jewelry, artifacts?
If so list of items
How involved is resident with their own decisions
Is there an exploitation prevention system in place?
If so who over sees it and what does it entail
Are there any concerns with family members abusing residents money?
Does family or otherwise have access to cash and credit cards?
If so who, and who keeps the financial files?
RESTRICTIONS:
If any, what are the residents restrictions?
What are they prohibited from participating in and what are the most critical restrictions?
FACILITY:
why did you choose this facility?
What are its strengths?
Weaknesses?
How long at this facility?
Is this their first facility?
Any concerns with care?
What are their living conditions?
How well does resident interact with staff and other residents?
Will resident object to Protective Service Agency services?
Have restraints been approved or utilized?
If so for what and how often?
Is there a back up plan for relocation should it be required?
Are there staff problems?
Do the staff work well together?
Are there adequate number of staff per resident?
How many residents are each staff member caring for at one time?
Does the resident get along with the staff?
Have there been any incidents/reports with staff?
Are the staff trained to meet the medical needs of the resident?
Are the staff trained in behavioral issues with residents?
Are the staff professional and helpful?
Are the staff informative?
Who cleans the residents room and possessions?
Who provides bedding, sleep ware and towel?
Who provides toiletry supplies?
Are they adequate?
ACTIVITIES:
what type of activities does the resident participate in?
Are they capable of participating in activities?
Does the resident drive?
If so how often?
Who provides gas?
What type of vehicle?
Does the resident participate in off site activities?
If so how often?
What type and where?
Who is responsible for them while off site?
Does the resident participate in any water activities?
If so where and how often?
Who oversees this activity?
Does the resident participate in physical activities like sports or exercise?
If so what type and how often?
Is there an activity log?
If so who keeps it?
NUTRITION:
How many meals a day?
What time do they eat?
How many snacks a day?
What time are snacks?
Is the resident on a special diet?
Are there any food allergies?
Who is responsible for assuring the resident eats?
Does the resident eat in the dinning hall or their room?
What type of beverages do they drink?
Are they getting enough water intake?
Who assures water consumption?
Does the resident take supplements?
If so, who assures intake?
What type?
How often?
Does the resident have a nutritionist?
What is the quality of the food?
Are the meals prepared on site or catered?
Does the resident have access to food other than that provided by the staff?
If so what type and where?
Do any visitors bring food?
Does medication need to be taken with food?
If so who administers?
Have there been any problems with diet or food quality?
Does the resident over eat or under eat?
Does resident consume a lot of dairy and sugar?
Has there been weight gain or loss?
If so is it frequent?
How many times has weight changed?
VISITATIONS
Does the resident have visitors?
If so who visits?
How often?
Are there any restrictions on who visits?
If so, who?
Is there anyone not allowed to visit?
Does the resident visit anyone off site?
If so who?
Are there any family members in dispute over the resident?
Have there been any problems with visitors?
How close is the nearest family member?
Is someone in charge of visitations?
Are visitations limited to specific days or hours?
If so what is the visitation schedule?
Is there a visitation log?
If so who keeps it?
Is there anyone the resident does not want visiting?
If so who and why?
AGENCIES:
Does the resident have a case manager?
If so who, does the resident have legal representation?
If so who, are there any agencies involved with the resident?
If so, what agencies?
What is their role?
Does the resident receive entitlements from the government?
If so, what type and who oversees them?
Who keeps the files?
I,
legal guardian for,
Approver email address
Approver Signature
Date consent signed
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