SSC Referral Questionnaire

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Should you need assistance please call 720-773-0253.
Type N/A if the questions do not need to be answered.

Candidate's Name *

Candidate's Date of Birth or Age *

Name of Referring Individual and/or Provider *

Referring Contact Number *

Referring Email Address *

Where are you currently living?
*

Where are you (candidate) currently located? *

If you are completing this for on behalf of someone else, what is your relationship to that residential candidate? *

What is your (candidate's) gender? *

Female

Male

Prefer not to say

Other:

Are you on Long Term Care Medicaid? *

Yes

If not, where are you in the process? *

If on Long Term Care Medicaid or Pending Long Term Care Medicaid, who is your Case Manager and what is their phone and email? Please indicate your MEDICAID ID. *

Are you on the BI Waiver? *

Yes

If not, where are you in the process? *

What is your timing for a move? *

Are you on Social Security or Social Security Disability Income? *

Yes

If not, where are you in the process? *

Do you have a criminal history? We do complete a background search prior to admission so please be honest. A criminal history does not exclude you from candidacy depending on the nature of the crimes and when they occurred. *

Do you have any history of aggression like hitting, screaming, or throwing objects at your peers or caretakers? *

Yes

Do you have a history of drug or alcohol abuse? *

How long ago was your brain injury? What happened? *

Where do you find yourself requiring help? *

Bathing and Grooming

Dressing and Undressing

Meal Preparation and Feeding

Transferring to/from bed

Safe Restroom Use

Walking

Required

Can you walk unassisted? *

Yes

Do you require a wheelchair or cane? *

Yes

Do you have a guardian or payee? *

Yes

If so, who is your guardian and/or payee? *

What do you need most in a living environment? *

Would you consider yourself clean or messy? *

Clean

Messy

Both

What type of roommates do you work well with? *

What type roommates do you NOT work well with? *

Anything else we should know? *

How did you find us? *

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