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Forms
The enrollment package includes an:
- Application
for Sliding Scale Fee - We offer services on
a sliding scale fee This form is used to determine
eligibility
- Registration
Form -
gives the address of the client, caregiver's phone
numbers, people allowed to pick up the client here at the
facility, and the client's doctors names and phone
numbers.
- Food
Program Eligibility - Food Program income
eligibility application
- Policies
and Admissions Agreement - Describes the
types of services that our facility will offer and the
policies of the agency.
- Medical
History Form - is to be filled out by the
client's physician. This form may be given to the family
or faxed directly to the physician's office.
- Medications Form - is filled out and any medications to be administered at the center are discussed with the nurse. Medications are required to be in duplicate prescription bottles
and may be brought to the center daily or a supply left at the center. It is the family's responsibility to notify the nurses of any medication changes.
- Release Form - which gives the center permission to take a client's pictures and use them in different promotions for ALPS, is discussed with the family. The family
decides whether or not they do or do not want their loved one to be photographed.
- Waiver of Liability Form - is required to be signed.
- Activities of Daily Living Check List - is completed by the family to give us a basic idea of what the client can do for themselves or where they require assistance.
- Items
to Bring - Items to bring with the participant on
the first day
- Photo-Voice
Release - gives the center the right to use photos
or voice recordings of participants
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