Group Home Admission

Resident Demographics

Basic identifying information for the new resident

First Name *

Last Name *

Date of Birth *

Gender

Admission Date *

Room / Bed

Medicaid ID

Social Security # (last 4)

Primary Disability / Diagnosis

Primary Diagnosis *

Secondary Diagnosis

Diagnosis Notes

Emergency Contact

Contact Name *

Relationship

Phone *

Email

Legal Guardian / Conservator

Guardian Name

Guardianship Type

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Step 1 of 5

Waiver & Funding

Medicaid waiver type, funding source, and case management

Medicaid Waiver Type *

DD Waiver

CADI Waiver

TBI Waiver

CAC Waiver

AC Waiver

MSC+

No Waiver / Private Pay

Funding Details

DHS Case Manager *

Case Manager Phone

Case Manager Email

County / Lead Agency

Authorization Start Date

Authorization End Date

Authorized Hours/Week

Monthly Rate / Budget

Service Authorization Number

Prior Living Situation

Prior Residence

Reason for Placement

Step 2 of 5

Support Level & ADL Needs

Determine the resident's daily support requirements

Overall Support Level *

Level 1 — Low

Primarily independent. Reminders and minimal supervision. Less than 2hrs direct support/day.

Level 2 — Moderate

Needs consistent support with several ADLs. 2–4hrs direct support/day. Frequent prompting.

Level 3 — High

Requires significant hands-on support. 4+ hrs direct support/day. Complex behavioral or medical needs.

ADL Assessment

Activity	Independence Level	Notes
Bathing / Hygiene
Dressing
Toileting
Eating / Feeding
Mobility / Transfers
Communication
Medication Management
Community / Transportation

Behavioral Support Needs

Behavioral Challenges (check all that apply)

Behavior Support Plan (BSP) on File?

Positive Behavior Support Strategies

Step 3 of 5

Health & Medical Information

Medical history, current medications, allergies, and healthcare providers

Primary Healthcare Provider

Physician Name

Physician Phone

Physician NPI

Clinic / Practice Name

Last Physical Exam Date

Current Medications

Medications List

Allergies / Adverse Reactions

Medical History

Active Medical Conditions

Seizure Disorder?

Seizure Protocol on File?

Mobility Aid

Diet / Swallowing

Safety & Precautions

Special Precautions (check all that apply)

Fall precautions Aspiration risk Choking risk Skin integrity issues Wandering / elopement No unsupervised access to sharps None

Specialists & Other Providers

Specialist / Other Providers

Insurance

Primary Insurance

Insurance ID / Member #

Insurance Group #

Step 4 of 5

Review & Confirm Admission

Verify all information before saving the resident record

Acknowledgement

I confirm the above information is accurate and the resident has been properly assessed prior to admission. The resident's guardian / representative has been informed of house rules, rights, and services. All required documentation (waiver authorization, physician orders, BSP if applicable) is on file or pending.

Step 5 of 5

🏘

Resident Admitted!

The resident has been added to the group home. Their chart, progress notes, and daily support log are now active.

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