R2. Renown Respite Intake Form

Client Legal Name*

First NameLast Name

Preferred Name & Pronoun

Intake Date*

Date

Birth Date*

Date

Prior Client?*

YesNo

Gender?*

MaleFemale

Take Photo*

Race/Ethnicity?*

Emergency Contact and Phone #*

Any Contact or TPO orders? If yes, please provide detailes.

Is resident involved with ANY type of criminal justice circumstances? (Jail, prison, specialty court, community court, parole, probation, etc.?)*

YesNoOther

Medicaid Insurance Provider*

Medicaid Insurance Number*

Medicare Insurance Number*

Primary Care Physician*

Primary Care Physician Phone #*

Is resident diagnosed with...? (Choose all that apply)

Behavioral HealthSubstance AbuseMedical Health

Home Health Aid Name*

Home Health Aid Phone #*

Known Allergies

Known Food Senitivities or Special Diet

List all Required Medication or upload pictures of med list*

Upload Photo of Medication List

Does Resident Have Any of the Following Symptoms (choose all that apply)*

In the Past 14 Days, Has Resident Been in Close Physical Contact (6 feet or less) with any of the Following? (choose all that apply)*

I acknowledge, by signing this documents, I agree to enter into a Respite Bed with Life Changes, Inc. for the purpose of healing and stabilization associated with my medical needs. My signature on this agreement acknowledges that I am fully aware of and agree to abide by the Life Changes, Inc. conditions for temporary residency. These conditions are as follows:

I agree to refrain from the use of all non-prescribed mind or mood-altering substances, including alcohol, and refrain from participating in any form of Gambling on or off site, residents must further agree to random urinalysis and breathalyzer tests. All residents of the Life Changes Respite Home are subject to random drug/alcohol screening and room searches, violation of these rules could result in consequences up to and including termination of program services.
Violence, including all forms of physical, mental, sexual, or emotional abuse, intimidation, injury, maltreatment, exploitation, or harassment is strictly forbidden.
Residents will be held financially responsible and can be terminated for vandalism to company property. Resident is responsible for the cost of repair or replacement of any damages or destroyed property at Life Changes, Inc for which they are responsible.
All residents are required to report any damage or theft to management.
Thievery is not tolerated. Residents are responsible for their own possessions. Life is not liable or responsible for missing items. Staff has the right to search your possessions if alcohol, narcotics, weapons, contraband, trafficking, or theft is suspected.
No smoking is permitted within 10 feet of the Life Changes Respite Home facility is only allowed in designated areas.
You may not have visitors in your room. All visitation is to take place in common areas and is to be approved by Life Changes staff prior to the visit. Pets or animals are ONLY allowed based on company approval.
Sexual activity of any kind is prohibited on the Life Changes Respite Home premises.
Resident of the Life Changes Respite Home are not authorized to enter another residents’ sleeping quarters unless it is your assigned roommate.
Residents are required to use the sign in/out sheets when leaving the Life Changes Respite Home. If your medical condition precludes you from clearly entering information on the sign in/out sheet, you may ask for assistance from an on-duty Life Changes staff member. All fields must be completed and legible. Include your full name, time of departure and anticipated return. You must use your legal name, NO NICKNAMES. If you are unable to return at your indicated time, you must contact staff immediately to obtain permission to be late.
At no time are you to sign in/out on behalf of another resident of the home or ask another resident to sign in/out on your behalf.
You are required to adhere to curfew as posted unless curfew interferes with your medical treatment plan. If you are unable to adhere to the posted curfew you must communicate this to Life Changes staff and indicate your anticipated return time and location on the sign in/out sheet.
You are required to take your medication as prescribed and adhere to all medication management policies and safe keeping requirements of the Life Changes Respite Home. Approved prescription medication drugs must be included in the resident prescribed medication information sheet. Prescribed medication must follow the Company’s Medication Management policy. There is no exception.
You are required to actively engage in your medical treatment plan and sign and maintain consent for company staff to speak with resident’s treatment team, and other collateral sources.
You are required to keep your personal area clean, pick up after yourself and be able to perform your activities of daily living.
Upon discharge, you must remove all your personal belongings. If your property is not removed within thirty (30) days, it will be considered abandoned. If you are unable to personally remove your property, you may give written authorization for a person of your choosing to retrieve your property.
You are required to dress appropriately at all times while residing in the Life Changes Respite Home. (No provocative clothing, appropriate coverage, no gang or drug logos on clothing)
Resident will respect the privacy and confidentiality of all house residents and will not disclose to anyone outside the household the names or any other information about who resides at any residential facility owned or operated by the Company.

I understand that by violating any section of the Code of Conduct, I face the following consequences:

Written notice given for rule breakage.
Required to be put on a behavioral contract for a minimum of seven days.
In the case of harassment, illegal behaviors, possession of drugs or weapons, trespassing, thievery, or behaviors that might otherwise jeopardize staff or other residents, I will be asked to stop and if I refuse to do so, with input and support from my health plan, I will be assessed for a higher level of care and will face possible discharge from the Life Changes Respite Home.

Residents Signature

Staff person completing form*

Additional Comments?

Renown Respite Intake Form

COVID/Monkey Pox Screening

Code of Conduct