Facebook Twitter Youtube Pinterest
Book An Appointment

Questionnaire

Self Assessment

To be completed by Applicant or Authorized Representative
Applicant's Full Name

Personal Care

Do you need assistance with any of the following daily activities? (please check)*
Bathing
Dressing
Toileting
Eating/Feeding
Walking
Wheeling
Transferring
Medication Management
Do you ever experience any of the following? (please check)*
Bowel Incontinence
Bladder Incontinence

Medical/Health Status

Do you have any current medical conditions, including mental health diagnosis, prior surgeries, or injuries:(Required)
Are you currently on any medications?(Required)
Do you have difficulty with your vision, hearing, or speech?(Required)
Please check all special treatments currently needed:

Financial Needs

Do you have medical insurance?(Required)
Do you have Medicaid?(Required)
Please upload copies of insurance cards, monthly income verifications (Social Security, pension, etc.), three months of bank statements for all assets (checking, savings, IRA, etc.), and a copy of Power of Attorney and Advance Directive:
Max. file size: 256 MB.
Is the Applicant filling out this form?(Required)
Name
Address
Please Note: TNT Residential Care primary goal is to care for our residents safely with respect, compassion, and dignity. While we truly want our residents to remain with us throughout their lives; there are times when their conditions may change beyond our ability to care for them safely and to meet all their medical needs. If a decline in condition prevents us from meeting this goal, staff will facilitate a transfer to a Residential Care Home that can provide the appropriate level of care.

Where we provide quality, commitment, and care for all adult with mental health disorders. Our goal is to help. TNT Residential Care foundation rooted in empathy and understanding, our devoted team offers bespoke support tailored to each individual’s unique journey.

Read More

Quick link

  • Home
  • About Us
  • Our Services
  • Careers
  • Contact Us
  • Book Appointment

Our Programs

  • 24 hour Care
  • Medication Management
  • Transportation ( Medical)
  • Single and Double Rooms
  • Case Management ( 3rd party)
  • Individual and Group Therapy ( 3rd party)
  • Daily Meals and Snacks
  • On Site Laundry
  • Utilities Included
  • Landline Phone

Short Info

Facebook Twitter Youtube Wordpress

Copyright © 2024· TNT Residential Care · Website Design by SpringHive