Housing Applications | Mental Illness Support

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Date

Applicant Name(Required)

First Last

Marital Status

Date of Birth(Required)

Do you have prior military experience?(Required)

Yes

Have you spent any time enrolled in a VA program?(Required)

Yes

What is your military status?(Required)

What is your discharge status?(Required)

Address(Required)

Street Address City State ZIP Code

Primary Phone(Required)

Alternate Phone

Gender(Required)

Male

Female

Other

Ethnicity(Required)

African-American

White

Pacific Islander

Hispanic

Other

Highest Level of Education Completed

High school diploma or GED

Associates degree

Bachelors degree

Masters degree

Private Pay or Other Arrangement?(Required)

Private Pay

Other Arrangement

Please describe other arrangement.

Income sources available to applicant:

List any services that the applicant is currently receiving (Medicaid, Medicare, Social Security, food stamps, medical specialties, therapies such as occupational, physical, speech, etc.):

Does the applicant have medical insurance? If so, list company, contact person, and policy number:

Please check the tasks that the applicant has been able to do for themselves in the past year (these abilities are not necessary for admission)

Is there a family member or concerned person(s) who would like to assist in any of the areas listed above? (Not necessary for admission)

Yes

Assisting Person's Name

First Last

Assisting Person's Relationship

Assisting Person's Area of Assistance

Name of person(s)/address/phone number of an alternate person who should be contacted if there is an emergency and staff is unable to contact a guardian, family member, or sponsor:

Briefly state the applicant’s personal and psychological history:

Has the applicant ever been arrested or convicted of a crime? Please list and explain (does not affect the applicant’s eligibility for residency):

Religious preference, name of church, pastor, etc. - (Optional)

Health Information

Psychiatric diagnosis:

Age of onset:

Psychiatric care provider:

Psychiatric care provider's phone:

Psychiatric care provider's address:

Street Address City State ZIP Code

Current psychiatric medications (at time of admission):

Current NON-psychiatric medications:

Known Illnesses and/or medical conditions:

Known Allergies:

Special Diet:

Current physician(s), dentist(s), specialist(s) who provide medical care for applicant: (list name and telephone number:

Has the applicant ever had an addiction, alcohol, or substance abuse problems? If so, give details:

Does the applicant currently have addiction, alcohol, or substance abuse problems? Explain:

Does the applicant have a guardian? If so, please list the name of the guardian, contact number, and physical address. Please attach the guardian paperwork if applicable.

Has the applicant suffered a traumatic brain injury? If so, give details:

Check any that apply to applicant:

Please list any surgeries, with name of doctor, type of surgery, and year:

Finances

Resident Name

Financial allowance amount

Financial allowance interval

I, the above named resident, request the assistance of the Administrator of NAMI Group Home to manage my finances and issue my personal allowance in the amount and intervals specified above. I understand I will receive a quarterly statement as verification from the Administrator.(Required)

First Choice

Second Choice

Please accept or decline the above statement.

List any individual details which apply to the resident’s financial arrangement:

Does this financial arrangement include a spouse, guardian, next-of kin, or sponsor?(Required)

Yes

Spouse, guardian, next-of kin, or sponsor's name:

Financial Responsibility

Person responsible for payment:(Required)

Relationship to applicant:(Required)

Service Agreement

NAMI Central Georgia Group Home agrees to provide the following basic care services:

Protective care and watchful oversight
24-hour a day lodging
Supervision of personal care
Supervision of nutrition
Medication management
Continuous assessment of needs and condition
Referral for appropriate services as needed
Correspondence between physicians, psychiatrist, social workers, lawyers, etc.
Correspondence of information to guardian, sponsor, or next-of kin regarding resident’s needs
Emergency transportation
Transportation to & from local appointments
Transportation to & from recreational activities
Life-skills Training
Laundry facilities (& detergent)
30 day written notice prior to changes in charges or services
30 day written notice prior to discharge**
- ** This does not apply to eviction due to violation of house rules, illegal or violent actions, or residents who are not medication compliant
- ** This does not apply to residents who develop a communicable disease or who require full-time nursing or psychiatric care.
- ** This does not apply to residents who fail to make regularly on time payments
In the case of indigent residents, NGH will provide clothing where applicable.
In the case of indigent residents, the home will arrange for provision of hygiene supplies.
Educational classes and resources
Support Groups
Case Management Plans
Community Integration

ANY SERVICE NOT LISTED HERE BUT REQUIRED IN THE PERSONAL CARE HOME REGULATIONS FOR THE STATE OF GEORGIA, WILL BE PROVIDED.

A COPY OF THE PERSONAL CARE HOME REULATIONS OF THE STATE OF GEORGIA WILL BE PROVIDED TO THE RESIDENT/GUARDIAN/SPONSOR UPON REQUEST

Resident's Signature(Required)

First Last

Date(Required)

Guardian's Signature

First Last

Date

Applications

NAMI Central Georgia is accepting applications for housing.

Health Information

Finances

Financial Responsibility

Service Agreement