Senior Helping Hands 2023 Application

Thank you for your interest in our Senior Helping Hands program. Please complete the attached application and return it to Big Sky Senior Services, 935 Lake Elmo Drive Suite B, Billings, MT 59105. 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:

o   Currently living in Yellowstone, Stillwater, or Carbon County

o   Must be at least 60 years of age

o   Have a diagnosed chronic health problem which prevents or restricts the client's ability to perform chores or personal care

o Not eligible for similar services through Medicaid or Veterans Affairs.

o   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 (406) 259-3111 if you have any questions.

Thank you

Lonna Landon

Senior Helping Hands

Program Manager
Applicant Information
Name*

Last NameFirst Name
Address*

Street Address

Apartment Number

CityCounty

Postal / Zip Code
Email
example@example.com
Phone Number*
Please enter a valid phone number.
Cell Number
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Gender*

MALEFEMALE
Race/Ethnicity

CaucasianNative AmericanHispanicAfrican AmericanHawaiian Pacific IslandAsianOther
Name of Spouse

First NameLast Name
Spouse Date of Birth

MonthDayYear
Date
Household Information
Housing:*

OwnRent
Type:*

HouseApartmentTrailerOther
Pets:

DogCatBirdOther
Emergency contact for client information or questions about care (ex. spouse, family member, or friend)
Emergency Contact Person*
Relationship to Client*
Address*

Street Address

Apartment Number

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number*
Please enter a valid phone number.
Cell Number
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Additional contact person not living with client (someone who has a key or access to home)
Contact Person
Relationship to Client
Address

Street Address

Apartment Number

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Cell Number
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
List all persons living in your home and their relationship i.e., self, husband, son, daughter, grandchild, niece, nephew, renter, etc.
1.
Relationship to Client
2.
Relationship to Client
Please use extra space at the bottom of application to list additional people.
Health Information
Is there a Providers Orders for Life-Sustaining Treatment (POLST) or AdvancedDirective posted on your refrigerator?*

YesNo
Health issues/concerns:
Physician Name
Please use extra space at the bottom of application to list additional physicians or specialists.
Physician Phone Number
Please enter a valid phone number.
Pharmacy
Specialist Name
Specialist Phone Number
Check any programs you are currently enrolled in

Meals on WheelsFood StampsLIEAPMedicaidMedicareFood CommoditiesOther
Client signature or signature of person submitting application*

Clear
Date

MonthDayYear
Date
Monthly bill will be paid by*
Referrals (Please complete this section if this is a referral.)
Is this a referral from another person or organization?*

YesNo
Name of person or organization referring
Relationship to applicant
Reason for referral
Referrer's Contact Information
Email
example@example.com
Phone Number
Please enter a valid phone number.
Hours of services: Monday – Friday 8:00 to 5:00

*Clients on a limited income may qualify for a cost sharing program which helps defray the hourly rate.

If interested, please contact office (406) 259-3111.*

Homemaking Services

(Cleaning supplies must be provided by client)

Please check the type of service you are requesting and frequency.
Homemaking services needed:

LaundryVacuuming/FloorsDustingBathroomMeal PreparationGrocery/Pharmacy ShoppingKitchen/DishesGarbage
How often needed

WeeklyEvery other weekMonthly
Rate: $24/hour* (1 hour minimum, 2 hour maximum)
Certified Nurse Aid
Personal Care services needed:

BathingHair CareSkin CareAssistance w/ dressingRange of Motion Exercise
How often needed:

1 X Week2 X Week
Includes supervision and instruction during bathing to insure safety of client and staff at no charge.

Rate: $24/hour* (1 hour minimum)
Respite Care Services

Respite care is provided for caregivers of 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 4 hours per visit.

WeeklyEvery other weekMonthly
Rate: $24/hour* depending upon client care (1 hour minimum)
Registered Nurse
Registered Nurse services needed:

Vital signs and brief review of symptomsMedication set-ups/pre-filling of insulin syringesHome safety and support systems assessment and client’s physician is notified of services provided at no charge
Rate: $34/hour* (1 hour minimum)
Please enter additional information here.
Should be Empty:

Applicant Information

Household Information

Emergency contact for client information or questions about care (ex. spouse, family member, or friend)

Additional contact person not living with client (someone who has a key or access to home)

List all persons living in your home and their relationship i.e., self, husband, son, daughter, grandchild, niece, nephew, renter, etc.

Health Information

Referrals (Please complete this section if this is a referral.)

Referrer's Contact Information