Volunteers of America Oregon

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Accepted: : Declined: Participant Contact Information Center: Marie SmithCenter 4616 N Albina Ave, Portland OR 97217 (503) 335-9980 (503) 335-0993 Client Information Name: DOB: Age: Gender: Marital Status: Referral Source: Immigrant: Veteran: Living Situation: Ethnicity: Language(s): Religious Preference: Transportation Caregiver: Tri-Met Lift: Medical Transportation: Other: Visitors At The Center: Volunteers of America Oregon Office Use Only Client/CG offered copy of intake packet: Is there anyone that should NOT visit the participant at the center? If "", please list and explain. Case Management Information Case Manager: Emergency Contact Information Primary: Cell: Relation: Secondary: Cell: Relation: Physician Contact Information Primary: Secondary: Participant's Health Insurance: Participant's Hospital Preference: Billing Information Billing Method(s): Private Pay: Medicaid: VA: OPI: Responsible Billing Party: Relationship: Prime or ID #: VA#: Medicaid Branch #: Authorized # of Days: Page 1of5

Participant Health Information Advanced Directives Does the participant have a POLST (or other advanced planning document)? Other Health Care Professionals Diagnosis and Health Concerns (Please mark with an "X" for diagnosis or "M" if medications are taken) Dementia Diabetes Dizziness Hypertension Stroke Thyroid Problem(s) Mental Health Arthritis Heart Disease Parkinson's Allergies (Please list any food, drug, animal, or other allergy below) Seizures Osteoporosis Alcohol/Drug Abuse COPD Skin Problems Respiratory Issues Cancer Other Concerns: Does Participant smoke? Can they smoke safely and independently? Did they smoke in the past? How Long? Will they smoke at the center? When did they quit? Sensory & Communication Vision: Blind Glasses: Deaf Hearing Aide: Concerns: Hearing: Concerns: How well can the participant comprehend others? Can they communicate their needs? Dining Needs (*Please note: family must provide food for special diets such as vegan, kosher, gluten-free, etc) Eats Independelty: Diet (Check all that apply) Regular Diabetic Vegetarian Vegan* Soft Puree Pre-cut Small Portion Ensure or other supplements? If "", needs: Cues (Must be supplied by family ) Prompts 1 on 1 Kosher* Gluten-Free* Other (Write below) If, please specify: Fluid Restrictions: Needs Thick Liquids? If "", please explain: At Risk for Dehydration? Special Instructions, if any: Page 2 of 5

Participant Health Information Mobility (Please check all that apply) Stand-by assist Does participant have an exercise program? W/C Walker Cane Quad cane Fall risk Transfer Assistance (Please check all that apply) Stand-by assist Needs cueing 1 person assist 2 person assist Comments: Sleep Does participant need to nap at the center? Sleep pattern: If "", how long? Describe any problems/concerns: Wandering/Confusion Does participant try to leave regularly? Redirection techniques you find helpful: Are there any of the following behaviors related to confusion that we should know about? Anxiety Physical Outbursts Verbal Outbursts Hallucinations Delusions If so, please explain: Restrooming Toileting: Needs to be shown bathroom Wears pads has/needs toileting schedule Needs assistance in bathroom Needs Reminder Bladder: Uncontrolled bladder incontinence Catheter Bowel: Constipation Frequent bowel incontinence Frequent diarrhea Known causes of diarrhea?: Frequent UTIs Colostomy (must be self-maintaining) Please describe the assistance needed or any concerns regarding toileting: Additional Services (Please select any services that you'd like the participant to receive) Wander Tag Blood sugar testing (if diabetic) Nurse consultation Nail care Insulin injection Medication administration Foot care* Blood pressure monitoring Functional maintenance therapy Shower (w/assistance)* Weight monitoring Caregiver support group Assistive Dining UTI Screening/Testing *Fee for service I have reviewed the information on this form, and to the best of my knowledge, it is accurate. X Participant/Caregiver signature Page 3 of 5

Volunteers of America Permissions Authorization for Emergency Medical Treatment Please read the Emergency Medical Treatment Policy before signing. If the participant is found to be pulseless and not breathing: Day center staff has permission to perform CPR until EMS personnell arrive or the participant begins to breath on his/her own. The participant has/will submit a POLST or DNR that shows he/she does not want to be resuscitated. Staff should honor these orders. te: This form alone cannot act as a POLST or DNR order. The day center must have current POLST or DNR orders on file upon enrollment in order to honor the participant's wish to deny resuscitation. If the day center does not have these documents on file, staff WILL start CPR if the participant is found to be pulseless and not breathing until EMS personnel arrive or the participant begins breathing on his/her own. Urine Dip Screening Permission If the day center staff suspects that the participant may have a urinary tract infection, the day center RN or designee: has permission to collect urine fromhim/her and do a urine dip screening for a UTI. does not have permission to collect urine fromhim/her and do a urine dip screening for a UTI. Media Release Permission Occasionally, Volunteers of America Oregon may use photos and/or video footage of participants for advertising purposes. This includes, but is not limited to: TV/radio, internet ads, brochures, newsletters, and social media (Facebook, Twitter, etc). This authorization may be revoked at any time. I allow Volunteers of America to take photographs and/or video footage for the reasons state above. I do not allow Volunteers of America to take photographs and/or video footage for the reasons state above. Outings Permission Approximately once a month the day center will go on an outing. It can either be a scenic drive or a trip to a local attraction that may require getting off the bus. Every outing will be adequately staffed with day center staff and volunteers as needed to meet the needs of the clients attending. Participation in these trips is strictly voluntary. The day center also reserves the right to decline taking a client for reason including, but not limited to: medical needs, potential wandering, behavioral issues, excessive incontinence issues, limited space, etc. may participate in outings offered by the day center. Participant name may not participate in outings offered by the day center. Policies and Procedures Review Attached to this intake packet are the following VOA policies: "Services, Eligibility, Payment, and Billing Agreement", "Participant Rights", "Emergency Medical Treatment Policy and Procedures", and the "tice of Privacy Practices". Please take a moment to review the policies and then sign below. The day center has provided me copies of the policies listed above. I have read and understand the policies and procedures set forth by VOA and the day center. Participant Name Family/Care Giver Name Participant/Care Giver Signature Page 4 of 5

Volunteers of America Oregon Adult Day Services Authorization for Release of Information Participant name: DOB: I hereby authorize Name of physician, LPN, therapist, medical professional, etc Address City Telephone Number State Zip Fax Number To Disclose To and Receive From: Volunteers of America Oregon Adult Day Services Programs. Marie Smith Adult Day Center: 4616 N. Albina Street, Portland, OR 97217 fax: 503-335-0993 Lambert House Adult Day Center: 2600 SE 170th, Portland, OR 97236 fax: 503-760-2192 The following information from my records (mark all sections below yes or no ): Admission Lab work Insurance/billing Discharge information Nursing assessment Care plan information Medication list Case management notes Diagnosis Other: The purpose of the exchange or disclosure of information is to (mark all sections below): Plan treatment/services Facilitate on-going treatment/services Summarized treatment Coordinate discharge Other (specify) Volunteers of America Oregon cannot condition treatment, enrollment or eligibility if the above named person refuses to sign this form. I understand that this consent is subject to my revocation at any time except to the extent that action as already been taken as a result of my signed agreement. Unless I revoke my consent, this agreement will remain in effect for 90 days from the date of my discharge. Once we disclose the information it may no longer be protected by Federal HIPAA privacy laws. Signature VOAOR Adult Day Services Representative/Witness Revocation: I do hereby revoke my agreement to release or exchange any and all of the aforementioned information signified on this document. Volunteers of America Oregon will not withhold treatment or services for refusal to sign this form. Signature VOAOR Adult Day Services Representative/Witness Page 5 of 5

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