BIC R

Senior Helping Hands Application
Thank you for your interest in our Senior Helping Hands program. Please complete this application. Once your application is received it will be reviewed and we will call you to schedule a meeting.

Senior Helping Hands is a program of Big Sky Senior Services, a private, nonprofit agency. Our goal is to help seniors remain living independently in their own homes by providing respite care, homemaking, personal care and nursing services.
Eligibility for Senior Helping Hands program is as follows:
- Currently living in Yellowstone, Stillwater, or Carbon County
- Must be at least 60 years of age
- Have a diagnosed chronic health problem that prevents or restricts the client's ability to perform chores or personal care
- Not eligible for similar services through Medicaid or Veterans Affairs.
- Living independently (assisted living or retirement homes are not eligible for services)
For more information about our programs, you can visit our website at www.bigskyseniorservices.org. We look forward in assisting you. Please feel free to call Lonna at 259-3111 if you have any questions.

Thank you,

Lonna Landon
Senior Helping Hands
Program Manager
Big Sky Senior Services
935 Lake Elmo Dr., Ste. B
Billings, MT 59105
Phone 406-259-3111
Fax 406-259-5839
Date Received

MonthDayYear
Date
Client ID
Name

(First name,middle initial)Last name,
Phone#
Cell#
Social Security #
Date of Birth

MonthDayYear
Date
Referred to by
Gender

MALEFEMALE
Race/Ethnicity

CaucasianNative AmericanHispanicAfrican AmericanHawaiian/Pacific IslandAsianOther
Home Address
Apt #
P.O. Box #
City
Zip
County
Name of Spouse
Spouse DOB
Spouse Social Security #
Emergency contact for client information or questions about care (examples: spouse, family member, or friend)
Emergency Contact Person
Relationship
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State
Zip Code
Home Phone
Mobile Phone
Work Phone
Email
example@example.com
Additional contact person not living with client (someone who has a key or access to home)
Contact Person
Relationship
Address
City
State
Zip Code
Home Phone
Cell Phone
Work Phone
Email
example@example.com
List all persons living in the home and their relationship i.e., self, husband, son, daughter, grandchild, niece, nephew, renter, etc. (If there are more than 2 additional household members, please provide their information to Senior Helping Hands staff during intake meeting.)
Name
Relationship
Name
Relationship
Check if bill will be paid by another person

My bill will be paid by another person
Name of person who will pay your bill
Housing Status

RentOwnType:ApartmentTrailerOther
Please check all that apply

Elderly (over 62)1 - 4 Members living in HouseholdFemale Head of Household (with dependents living in your home)5+ Members living in HouseholdSingleDisabledVeteranI do not wish to furnish this informationDogCatBirdOther
Health issues/concerns
Physician's Name (note: if more than 1 physician, please provide information about additional physicians to Senior Helping Hands Staff during the intake meeting.)
Physician's Name
Physician's Phone Number
Pharmacy
Other Specialist's Name
Other Specialist's Phone
Is there a Providers Orders for Life-Sustaining Treatment (POLST) or Advanced Directive?

YESNO
Where is your POLST kept?
Check any programs you are currently enrolled in:

Meals on WheelsFood StampsLIEAPMedicaidMedicareFood CommoditiesOther
Hours of services: Monday - Friday 8:30 to 4:30 Please check the type of service you are requesting and frequency.

*Clients on a limited income may qualify for a cost-sharing program which helps defray the hourly rate. If interested, please include proof of household income bank statement with this application.*
Please select all services client might require:
Homemaking services needed: Cleaning supplies must be provided by the client. - Rate: $24/hour* (2 hr minimum) (check all that apply)

LaundryVacuuming/FloorsDustingBathroomMeal PreparationGrocery/Pharmacy ShoppingKitchen/DishesGarbage
Service frequency desired for Homemaking Services

WeeklyEvery other weekMonthly
Personal Care services needed, Certified Nurse Aid: Includes supervision and instruction during bathing to insure safety of client and staff at no charge. - Rate: $24/hour* (1 hr minimum) (check all that apply)

BathingHair CareSkin CareAssistance w/ dressingRange of Motion Exercise
Personal Care services needed

Once per weekTwice per week
Respite care is provided for caregiver clients requiring supervision, including clients with Alzheimer's. Respite care is delivered by a Homemaker or CNA depending upon the skills required during respite services. The Homemaker or CNA may provide homemaking and/or personal care while in the home. Respite care is scheduled weekly, not to exceed 2 hours per visit, or 4 hours per week.

Respite Care Services are required
Frequency of visits required for Respite Care

WeeklyEvery other weekMonthly
Registered Nurse Services:

Rate: $34/hour* (1 hr minimum) (Check all that apply)
Registered Nurse Services

Registered Nurse service is required
Registered Nurse services needed:

Vital signs and brief review of systemsMedication set-ups/pre-filling of insulin syringes Home safety and support systems assessment and client's physician is notified of servicesHome safety and support systems assessment and client’s physician is notified of services provided at no charge
Frequency of visits required

WeeklyEvery other Week
Applicant Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Senior Helping Hands Application

Hours of services: Monday - Friday 8:30 to 4:30 Please check the type of service you are requesting and frequency.

Please select all services client might require: