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Serving Southern Orange County, NY
and Sussex & Passaic Counties, NJ.

 

 


 

Family Information
(*) Required Fields  

*First Name:

 

*Last Name:

 
*Social Security #:
  
*Address:
  
*City:
  
*State
  
*Zip Code:
  
Email:
  
*Phone:
  
Fax:
  
Place of Birth:
 
Date of Birth:
 
Are You Married?:
Yes No  
Please answer the following if you selected No to the above question:
Single Divorced Widowed  
Name of Husband or Wife:
  
Address if living:
  

City:

 

State

 

Zip Code:

 

Persons to Contact in Emergency

  

1. Name

 

Address:

 

City:

 
State:
  
Zip Code:
  
     
2. Name
 
Address:
  
City:
  
State:
  
Zip Code:
  
     
3. Name
 
Address:
  
City:
  
State:
  
Zip Code:
  
     
Present Location of Applicant:
  
Personal Information
  
With whom are you living now?:
  
Relationship:
  
Describe your situation (i.e. own home, rental, 3rd floor walk up apartment):
  

Your profession or occupation
(previous, if retired):

  
Educational background:
 
How did you hear about us?:
  
Do you wish to remain active in your present religious group?
 Yes No  
If so, what is your religion?
  
What are your special interests?
(hobbies, music, art, birds...):
  
Additional information about yourself that we should know:
  
What are the major goals, skills or abilities you want to improve?:
  
Health History
  
1. Give dates and nature of any major illness or operations you have experienced
in the last ten years.
  
Previous Illnesses/Surgery/Hospitalization When
1.
2.
3.
4.
 
Family History
  
Hypertension:
 Yes No
Cancer:
 Yes No
Heart Disease:
 Yes No
COPD:
 Yes No
Epilepsy:
 Yes No
TB:
 Yes No
Diabetes:
 Yes No
Other (specify):
 
Medication History
  
Name of Drug
Dose & Time/Freq
Last Dose Taken
Patient’s Understanding
of Medication
1.
2.
3.
4.
5.
6.
 
Present diagnosis:
  
Name of present physician:
  
Address:
  
City:
  
State:
  
Zip:
  
Telephone#:
  
Have you ever been treated for any nervous or mental disorders?:
 Yes No  
If yes, when?:
  
Name of physician who treated you?:
  
Address:
  
City:
  
State:
  
Zip:
  
Telephone#:
  
Can you walk without assistance?
 Yes No  
If no, what kind of assistance to you need?:
  
Can you completely care for yourself without assistance?:
 Yes No  
Bathe?:
 Yes No  
Dress?
 Yes No  
Use Restroom?:
 Yes No  
Financial Statement
  
Monthly Income List Pension Source & Amount  
Social Security:
 $
Source:
Veterans Benefits:
 $
Amount:
 $
R.R. Retirement:
 $  
Dividends/Interest:
 $  
Trust Income:
 $  
Rental Income:
 $  
Other:
 $  
 
Bank Accounts    

1. Name of Bank:

 

Address:

 

City:

 
State:
  
Zip Code:
  
Acct#:
  
Title of Acct:
  
Balance:$
  
     
2. Name of Bank:
 
Address:
  
City:
  
State:
  
Zip Code:
  
Acct#:
  
Title of Acct:
  
Balance:$
  
     
Stocks and Bonds    

1. Name of Company:

 

Number of Shares:

 

Approximate Value:

 
     
2. Name of Company:
 
Number of Shares:
  
Approximate Value:
  
     
3. Name of Company:
 
Number of Shares:
  
Approximate Value:
  
Real Estate    

1. Location:

 
Approximate Value :$
  
     
2. Location:
  
Approximate Value :$
  
     
3.