<p>Gero-Psychiatric Nursing Facility Application Date: </p><p>1. Participant Information Name: DOB: Gender: M F Medicaid #: Medicaid LTC: Y N Medicare #: Address: Town: State: Maine Zip: Phone Number: Marital Status:</p><p>2. Current Facility Information (if applicable) Facility Name: Street Address: Mailing address, if different: Co un City: ty: State: ME Zip: Social Worker/Discharge Planner’s Name: Phone #: Email address: Admission date: (mm/dd/yyyy): Current (MED Assessed) level of care: Date of PASRR Level II (mm/dd/yyy): 3. Person/Agency Making Referral (if applicable) Name of Person/Ag ency: Street Address: City: County: State: ME Zip: Phone #: Fax #: Email address:</p><p>4. Legal Representative, Guardian, Power of Attorney (Provide a copy of paperwork to OADS with this application) Name: Street </p><p>Updated 1/20/17 Page 1 of 5 Address: City: County: State: ME Zip: Phone #: Alternate Phone #: Relationsh ip to Client:</p><p>5. Emergency Contact (i.e., Guardian, closest family member) Name: Street Address: City: County: State: ME Zip: Phone #: Alternate Phone #: Relationsh ip to Client:</p><p>6. Preferred Gero-Psychiatric Placement Living Preference: Consumer’s Guardian’s Comments Choice Choice (if applicable) Hawthorne House Gorham House Mount St. Joseph</p><p>8. Areas of Support Needed (check all that apply) Part A. Risks/Challenging Behaviors/Critical Support Needs Lack of orientation to: Risks: Behaviors:  self  Ineffective/unsafe response  Wanders – without clear direction  time in emergency of where he/she is going  place  Falls  Elopes – purposely tried to leave  Medication/treatment non- unnoticed compliance  Unaware of personal boundaries  Unaware of social cues  Intrusive to others space  Unable to manage interpersonal </p><p>Updated 1/20/17 Page 2 of 5 Within the residence: Difficulty with Memory: conflict  Difficulty navigating inside  Short Term Memory  Verbally abusive residence  Long Term Memory  Taking others property  Unsafe in the residence  Impacts Daily Tasks  Property destruction  Unsafe in the kitchen  Physical assaults  Lethal threats to self  Lethal threats to others Outside the residence: Difficulty with Language: Other Areas of needed support:  Disorientated outside  Expressive language  Unable to control eating residence  Receptive language  Inappropriate dress  Unsafe in the community  Significant lack of Traffic/Pedestrian motivation/initiation  Impulsive consumption/collection Unable to safely occupy own time:  less than one hour  less than three hours  less than 8 hours</p><p>Part B. Health & ADL/IADL Support Needs</p><p>INCONTINENCE EATING MOBILITY</p><p> bladder  swallowing issues  uses wheelchair  bowel  special diet  uses walker  requires direct support for  requires direct support for  uses cane toileting eating  requires direct support for  requires cueing/monitoring for  requires cueing/monitoring moving toileting  requires cueing/monitoring for moving</p><p>BATHING AND DRESSING SLEEP List any Specialized Nursing Care Issues  requires direct support for  awake at night bathing  sleeps less than 6   requires cueing/monitoring for consecutive hours at night  bathing  CPAP   requires direct support for  BIPAP  dressing   requires cueing/monitoring for  dressing</p><p>Updated 1/20/17 Page 3 of 5 IADLs (check item if help needed with this task)</p><p> household chores  money management  laundry  shopping  cooking</p><p>9. Medications Name of Medication Reason Prescribed Dosing Amount and Directions</p><p>Additional Comments/Information</p><p>Complete this application and fax along with all items listed below to: Neurobehavioral Services @ (fax) 207-287-9229 -or- (e-mail secure application to) [email protected] Updated 1/20/17 Page 4 of 5 (mail to:) DHHS - OADS Attn: Neurobehavioral Services 41 Anthony Avenue, SHS #11 Augusta, Maine 04333-0011</p><p> Release of Information  Power of Attorney, Representative Payee, or Guardianship Documents (if applicable)</p><p>Updated 1/20/17 Page 5 of 5</p>