Referral Application

Please complete as much of the form as possible!
The more specific information you provide, the more useful it will be for those responding to your request.

Click the check boxes below to select the facilities that will receive this application.

	Indian Hills Retirement Village - Chillicothe, Missouri
	Lake Ozark Retirement Center - Lake Ozark, Missouri
	Oak Tree Villas - Jefferson City, Missouri
	Ozark Meadows - Laurie & Osage Beach, Missouri
	The Villas - DeSoto, Missouri
	Westphalia Retirement Center - Westphalia, Missouri

Please provide the following information about the APPLICANT needing Long Term Care placement or services:

First Name:
Last Name:
Application Date:
Social Security Number:
Sex/Gender:
Date of Birth:	(mm/dd/yyyy)
Age: (if uncertain about birthdate)
Marital Status:
Citizenship:
Languages Spoken:
Family Contact/Guardian:
Current Street Address:
City:
State:
Zip Code:
Phone:

Please provide the following information about the FORM PREPARER making this referral:

Company/Organization:
Preparer's Name:
Title/Position:
Relation to Applicant:
Street Address:
City:
State:
Zip Code:
Phone:
Fax:
Email:
URL (Web Address):

Please provide the following information in order to help the different providers
assess whether their facility and/or services will meet your needs:

Reason for applying for services or residency:

What type of family or friend support can be expected?

Strong
Some
None

Type of Medical Insurance:

Is this a Medicaid referral?
(or soon will be)

No
Yes - When:

Is this a Medicare referral?
(or soon will be)

No
Yes - When:

Financial Arrangement (Payment Method):

Medical Overview

Physician's Name:

Medical History:
(Identify Primary/Secondary Diagnosis)

Height:

Weight:

List of medications
currently taking or prescribed:

Immunization History

Tuberculosis Clearance Date:

Chest X-Ray:

PPD:

Tetanus-Diptheria-Toxoid:

Pneumococcal Vaccine:

Influenza Vaccine:

Code Status:

Is this a Hospice Referral?

No
Yes

Does the individual need any of the following:

Medications by injections

Catheter

Dialysis

IV's

Open Sores/Special Skin Care

Tube Feeding

Ventilator

Inhalation Therapy

Special Diet
Description:

Therapy/Rehab Needs
Description:

Any other special medical needs?

Psychological Overview

Psychiatrist's Name:
(if different than above)

Psychiatric History:
Identify Primary/Secondary Diagnosis

Does this individual have memory problems?

No
Yes

Please Describe:

Does this person wander off?

No
Yes

Does this individual demonstrate any destructive behavior?

No
Yes

Please Describe:

Is this person at risk for frequent falls?

No
Yes

Does the individual need constant supervision?

No
Yes

Functional Assessment

Can the applicant perform the following:	Independently	With Assistance	Is not capable
Bathing
Dressing
Transferring (getting out of a bed or a chair)
Walking/Ambulating
Toileting
Feeding/Eating
Continence (Can maintain their bowel or bladder)
Can communicate independently
Hearing & Eyesight Problems	None	Complete/Partial Loss	Other
Hearing Problems
Eyesight Problems

Please list any assistive devices required (specify below):

Wheelchair		Walker
Cane		Glasses
Hearing Aid	Other:

Is there anything else you think that the provider needs to know about the individual looking for Long Term Care (LTC) accommodations/services? Any specific medical or behavioral needs that the LTC provider should be aware of?

Can all the information above be verified by a healthcare professional?

No
Yes

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