House of CAARE
Application for Admission
Name:___________________________ Date of Birth:_____________________
Social Security #:__________________
Address
Street:_________________________________________________________________
City:____________________________ State:_________ Zip:_____________
How long at this address?____________ Telephone:________________________
Previous Address
Street:_________________________________________________________________
City:____________________________ State:_________ Zip:_____________
Referred by:_______________________
Agency Name:_____________________
Address:_______________________________________________________________
Telephone:________________________
Current housing situation: Describe impact or relationship to applicant’s HIV disease. Use back page if necessary.
Medical History:_________________________________________________________
HIV diagnosis:_______________________
Name, address, and on-call phone number of primary care physician:
Recent Medical History: Include name of hospitals, dates of treatment, and nature of illness. Use back page if necessary.
List any other related or unrelated medical conditions, such as physical handicaps, mental illness, allergies, severe illnesses or injuries.
List any medications currently being prescribed:
Are you currently receiving medicaid? Yes______ No_______
Have you ever applied for special assistance? Indicate when and status:
| Are you: |
Yes
|
No
|
| Able to shop for yourself? | ||
| Able to cook for yourself? | ||
| Able to use stairs unassisted? | ||
| Able to use public transportation? | ||
| Do you own your own car? |
Are you currently connected with any community-based support services, such as Buddy Support, or home-health assistance? List agencies, contact persons, and phone numbers. List family members or friends if applicable.
Who should be contacted in case of any emergency?
Name:_____________________________________ Telephone:__________________
Address:___________________________________
___________________________________
Financial Resources (Include Bank Accounts and Real Estate)
Source: _____________ Address or Agency:____________Monthly amount:______________
I have read the information on this completed application for admission to house of CAARE and verify that it is true to the best of my knowledge. I understand false or misleading information can be grounds for denial of admission or dismissal from the program.
CAARE, Inc. does not discriminate on the basis of race, gender, color, religion, age or sexual orientation.
______________________ ____________________
Signature of applicant Date
_____________________________________ _____________________
Signature of Person assisting with Application Program and Title
Please return completed application to:
CAARE, Inc.
P.O. Box 15567
Durham, NC 27701
Has CAARE received:
Completed physician’s questionnaire?_________
Signed release of information? __________
Verification of income information?__________
Other information needed:_____________________________________________________