5. Emergency Contact (i.e., Guardian, closest family member) Name: Street Address: City: County: State: ME Zip: Phone #: Alternate Phone #: Relationship to Client: 6. Preferred Gero-Psychiatric Placement Living Preference: Consumer’s Guardian’s Comments Choice Choice (if applicable) Hawthorne House Gorham House Mount St. Joseph 7. Diagnosis (Mental Health Geriatric Nursing Facilities provide specialized services for older people with mental illness) Primary ICD-10 Secondary ICD-10 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 of – time in emergency where he/she is going place Falls Elopes purposely tried to leave – Medication/treatment unnoticed Unaware of personal boundaries Unaware of social cues Intrusive to others space Unable to manage interpersonal conflict Within the residence: Difficulty with Memory: Verbally abusive Taking others property Difficulty navigating inside Short Term Memory Property destruction residence Long Term Memory Unsafe in the residence Impacts Daily Tasks Physical assaults Lethal threats to self Unsafe in the kitchen 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
5. Emergency Contact (i.e., Guardian, closest family member) Name: Street Address: City: County: State: ME Zip: Phone #: Alternate Phone #: Relationship to Client: 6. Preferred Gero-Psychiatric Placement Living Preference: Consumer’s Choice Guardian’s Choice (if applicable) Comments Hawthorne House Gorham House Mount St. Joseph 7. Diagnosis (Mental Health Geriatric Nursing Facilities provide specialized services for older people with mental illness) Primary ICD-10 Secondary ICD-10 8. Areas of Support Needed (check all that apply) Part A. Risks/Challenging Behaviors/Critical Support Needs Lack of orientation to: self time place Risks: Ineffective/unsafe response in emergency Falls Medication/treatment Behaviors: Wanders – without clear direction of where he/she is going Elopes – purposely tried to leave unnoticed Unaware of personal boundaries Unaware of social cues Intrusive to others space Unable to manage interpersonal conflict Verbally abusive Taking others property Property destruction Physical assaults Lethal threats to self Lethal threats to others Within the residence: Difficulty navigating inside residence Unsafe in the residence Unsafe in the kitchen Difficulty with Memory: Short Term Memory Long Term Memory Impacts Daily Tasks Outside the residence: Disorientated outside residence Unsafe in the community Traffic/Pedestrian Difficulty with Language: Expressive language Receptive language Other Areas of needed support: Unable to control eating Inappropriate dress Significant lack of motivation/initiation Impulsive consumption/collection
Admission%20Application%20(Word).docx