Resident Application Form
Lynnwood Place Residential Assisted Living: Resident Application/Intake Form. The information provided in this form will be used for initial interest screening and an early assessment to determine the potential fit for our senior care home. Completion of this form does not guarantee admission. Our home has a limited number of available rooms, and placement decisions are made with the goal of ensuring the best possible match for both the resident and our care team.

Please note that we will also conduct our own in-person interview and assessment. If the information shared in this form does not align with observations made during that process, or if we determine that the placement would not be in the best interest of the resident or our community, we may decide not to move forward with admission.

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First and Last Name of Senior Resident *
Date of Birth *
MM
/
DD
/
YYYY
Current Address (street, city, state, zip) *
Current Address Listed is *
First and Last Name of Representative Completing the form *
Phone Number of Representative *
Email Address of Representative *
What is the best time of day to contact you (the representative)? *
Anticipated Timeline of Placement Desired *
Current Cognitive Functioning - Part 1: Can the resident accurately state the current date, year, and their location: *
Current Cognitive Functioning - Part 2: After hearing three simple words (ex: apple, table, penny) can the resident recall them after 5 minutes? *
Current Cognitive Functioning - Part 3: Can the resident follow a two-step verbal instruction? (ex: Pick up the pen and hand it to me.) *
Mobility Functioning - Part 1: Can the resident safely walk from one room to another? *
Mobility Functioning - Part 2: Can the resident move independently from a bed to a chair or from sitting to standing? *
Mobility Functioning - Part 3: Can the resident manage a single step or short flight of stairs? *
Activities of Daily Living - Part 1: Can the resident bathe or shower safely and maintain personal hygiene? *
Activities of Daily Living - Part 2: Can the resident feed himself/herself adequately? *
Activities of Daily Living - Part 3: Can the resident dress himself/herself in appropriate clothing? *
Activities of Daily Living - Part 4: Can the resident use the toilet independently and maintain continence? *
Risk and Support - Part 1: In case of a fire or other emergency, can the resident evacuate the building safely? *
Risk and Support - Part 2: Can the resident manage and take medications safely as prescribed? *
Risk and Support - Part 3: Is the resident able to recognize and avoid fall hazards in their environment? *
Current Conditions: Please check all that apply (medical records will also be thoroughly checked).
Current Conditions: Please check all that apply (medical records will also be thoroughly checked).
Lynnwood Place is a private-pay residential assisted living home. There are some situations where families can utilize long term care insurance benefits to apply to their payment. In general, do you have a family plan to accommodate payment? Check all that apply. *
Required
Is there anything else you would like to share with our management team?
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