Apply Now for Admission to the Foundation for Independent Living

Applicant Information

Applicant First Name

Applicant Last Name

Place of Birth

Applicant's Social Security Number

Applicant Address

Address

City

State

Postal Code

Country

Applicant Email

Applicant Phone

Emergeny Contact Person's Name

Relationship to Applicant

Date of Birth

Gender

Person Completing This Form

Family/Guardian Address

Address

City

State

Postal Code

Country

Family/Guardian Email

Family/Guardian Phone

Emergency Contact Phone

Guardianship Information

Guardianship Status

None

Partial Guardianship

Full Guardianship

Conservatorship

If Partial Guardianship, Full Guardianship or Conservatorship are selected, please send copies of paperwork to bcadet@filinc.org.

Guardian First Name

Guardian Last Name

Address

City

State

Postal Code

Country

Independent Living Information

Has the applicant attended any other independent living programs?

Yes

No

Name of Facility

From:

Address

City

State

Postal Code

Country

Facility Phone

To:

Contact Person

Add another facility?

Yes

**Please provide the applicant's current Independent Service Plan (ISP) by mailing it to bcadet@filinc.org. This is required

Name of Facility

From:

Address

City

State

Postal Code

Country

Facility Phone

To:

Contact Person

Add a third facility?

Yes

Name of Facility

From:

Address

City

State

Postal Code

Country

Facility Phone

To:

Contact Person

Activities of Daily Living (ADL's) Assessment

Levels of Assistance: Please use the slider to answer the following for each item. Selecting "1" indicates the prospective resident needs no assistance; "2" indicates minimal assistance is needed; "3" means moderate assistance is needed and "4" indicates a lot of assistance is needed.

Help With Personal Hygiene (1=None needed, 2=Minimal, 3=Moderate, 4=A lot)

0

Help Bathing/Showering (1=None needed, 2=Minimal, 3=Moderate, 4=A lot)

0

Help Dressing (1=None needed, 2=Minimal, 3=Moderate, 4=A lot)

0

Help Grooming (1=None needed, 2=Minimal, 3=Moderate, 4=A lot)

0

Help With Oral Care (1=None needed, 2=Minimal, 3=Moderate, 4=A lot)

0

Help With Feeding (1=None needed, 2=Minimal, 3=Moderate, 4=A lot)

0

Help With Eating (1=None needed, 2=Minimal, 3=Moderate, 4=A lot)

0

Help With Continence (1=None needed, 2=Minimal, 3=Moderate, 4=A lot)

0

Help With Mobility (1=None needed, 2=Minimal, 3=Moderate, 4=A lot)

0

Instrumental Activity of Daily Living (IADL's) Assessment

Levels of Assistance: Please use the slider to answer the following for each item. Selecting "1" indicates the prospective resident needs no assistance; "2" indicates minimal assistance is needed; "3" means moderate assistance is needed and "4" indicates a lot of assistance is needed.

Food Preparation (1=None needed, 2=Minimal, 3=Moderate, 4=A lot)

0

Cooking (1=None needed, 2=Minimal, 3=Moderate, 4=A lot)

0

Microwave Use (1=None needed, 2=Minimal, 3=Moderate, 4=A lot)

0

Toaster (1=None needed, 2=Minimal, 3=Moderate, 4=A lot)

0

Coffee Machine (1=None needed, 2=Minimal, 3=Moderate, 4=A lot)

0

Stove (1=None needed, 2=Minimal, 3=Moderate, 4=A lot)

0

Oven (1=None needed, 2=Minimal, 3=Moderate, 4=A lot)

0

Dishwasher (1=None needed, 2=Minimal, 3=Moderate, 4=A lot)

0

Washer/Dryer (1=None needed, 2=Minimal, 3=Moderate, 4=A lot)

0

Managing Medication (1=None needed, 2=Minimal, 3=Moderate, 4=A lot)

0

Food Shopping (1=None needed, 2=Minimal, 3=Moderate, 4=A lot)

0

Managing Finances (1=None needed, 2=Minimal, 3=Moderate, 4=A lot)

0

Vacuum (1=None needed, 2=Minimal, 3=Moderate, 4=A lot)

0

Dusting (1=None needed, 2=Minimal, 3=Moderate, 4=A lot)

0

Sweeping (1=None needed, 2=Minimal, 3=Moderate, 4=A lot)

0

Cleaning (1=None needed, 2=Minimal, 3=Moderate, 4=A lot)

0

Resident Health Information & Criminal History

Does the applicant regularly take any medications?

Yes

No

Please provide the names of medications, dosages and medication schedules:

Does the applicant regularly see a psychologist, therapist or counselor?

Yes

No

Please provide the name of the therapist:

From the list below, please select any items of which the applicant has a current history:

Please provide more detail about the applicant's condition:

Has the applicant been under general hospitalization?

Yes

No

Date Hospitalized

Hospital Name

Reason

City

Result

Has the applicant been under psychiatric hospitalization/Baker Act?

Yes

No

Date Hospitalized

Hospital Name

Reason

City

Result

Note: In addition to this form, you will need to provide the following required medical documents:

Latest physical examination report from primary doctor (no more than 1 year old).
Current psychiatric and/or behavioral reports.
Current psychological report (no more than 1 year old).

Send copies of these documents to bcadet@filinc.org.

Has the applicant ever been arrested?

Yes

No

Date of Arrest

Charge

Outcome of Charges

Add 2nd?

Yes

Date of Arrest

Charge

Outcome of Charges

Add 3rd?

Yes

Date of Arrest

Charge

Outcome of Charges

Has the applicant ever been convicted of a crime?

Yes

No

Is the applicant currently on probation?

Yes

No

Education & Employment History

Is applicant 25 years or younger?

Yes

No

List all schools attended:

School name:

Date Completed:

Address:

Contact Person:

Phone:

Add 2nd school?

Yes

School name:

Date Completed:

Address:

Contact Person:

Phone:

Add 3rd school?

Yes

School name:

Date Completed:

Address:

Contact Person:

Phone:

High School Diploma?

Yes

No

Degree Attained:

Regular Degree

Special Degree

GED

Is applicant currently attending school?

Yes

No

Projected date of completion:

Did applicant participate in special education track?

Yes

No

Can applicant read?

Yes

No

Can applicant write?

Yes

No

Employment History

Did applicant receive any specialized employment training?

Yes

No

Please provide details:

Has applicant received any type of vocational certification?

Yes

No

Please provide details:

Has applicant ever been employed?

Yes

No

Employer:

Title:

Duties:

Start Date:

End Date:

Add 2nd job?

Yes

Employer:

Title:

Duties:

Start Date:

End Date:

Has applicant ever been involved in volunteer work?

Yes

No

Please describe:

Social Information

Please explain:

Has applicant ever been involved with any social organizations or groups?

Yes

No

Please describe:

Does the applicant have a hobby?

Yes

No

Please elaborate:

Past Residences, Family Goals & References

Prior Residences

Name:

From:

Address:

To:

Phone:

Contact:

Add a 2nd residence?

Yes

No

Name:

From:

Address:

To:

Phone:

Contact:

Goals & Aspirations for Applicant

Personal Reference:

Name:

Phone:

Email:

Former Program Reference (if applicable):

Name:

From:

Address:

To:

Phone:

Contact:

Medical Reference:

Name:

Phone:

Email:

Detailed Resident Application

Before You Begin

Applicant Information

Guardianship Information

Independent Living Information

Activities of Daily Living (ADL's) Assessment

Instrumental Activity of Daily Living (IADL's) Assessment

Resident Health Information & Criminal History

Education & Employment History

Employment History

Social Information

Past Residences, Family Goals & References

Prior Residences

Personal Reference:

Former Program Reference (if applicable):

Medical Reference:

Documents to Send

Need a Hand With the Form?