Neighbor Application

Applicant Information

First Name

Last Name

Phone Number (if applicable)

Email (if applicable)

Address Line 1

Address Line 2

City

State

Zip Code

Applicant's Date of Birth

Is the applicant signed up or on any federal waiver programs? If so, which one(s)?

Primary Guardian Information

This could be a parent, sibling, or other caregiver.

First Name

Last Name

Phone Number

Relationship to Applicant

Address Line 1

Address Line 2

City

State

Zip Code

Occupation/Name of Company

Secondary Guardian Information

This could be a parent, sibling, or other caregiver.

First Name

Last Name

Phone Number

Relationship to Applicant

Address Line 1

Address Line 2

City

State

Zip Code

Occupation/Name of Company

How did you learn about Hilltop Ranch?

Help us get to know the applicant

Please describe the applicant's primary diagnosis (intellectual or developmental disability):

Please describe the applicant's secondary diagnoses (if applicable):

Please describe the applicant's general health, including special medical problems and/or physical disabilities:

Please describe the applicant's communication abilities:

Please describe the applicant’s social/emotional state most of the time (for example: withdrawn, hyper-verbal, frustrated, sociable, even-tempered, etc.):

What is the applicant's current living situation?

In what types of settings does the applicant thrive or do best?

In an ordinary day, in what ways does the applicant require support (hygiene, chores, self-care, etc.)?

Please describe the applicant's daily routines and leisure activities:

What do you think the applicant feels are his/her disabilities?

What are the applicant's specific aptitudes, interests, and/or strengths?

Does the applicant have a job or is he/she enrolled at a day program? If so, please provide the name of the employer or day program.

Has the applicant ever attended overnight camp or been away from home and family for several days? If so, how did the applicant handle this change?

Please describe activities, settings, or situations that the applicant strongly dislikes or struggles with.

Does the applicant have a history of romantic relationships?

Is the applicant pregnant, nursing, or may become pregnant?

Please describe your goals and expectations for the applicant and how you see Hilltop Ranch fitting into that vision.

Has the applicant ever seen a behavioral health specialist?

Yes

Does the applicant have a current care plan in place with his/her behavioral health specialist?

Yes

Has the applicant ever been involved with tobacco use, drug or alcohol abuse, criminal activity, or sexual misconduct?

Yes

If so, please explain.

Has the applicant ever been on probation, parole, or charged with a crime?

Yes

If so, please explain.

References

Please list three (3) individuals (church, employer, day program, etc.) who have worked with or known the applicant closely.

First Name

Last Name

Phone Number

Relation to applicant

Is it okay to contact this person?

Yes

Second Reference

First Name

Last Name

Phone Number

Relation to applicant

Is it okay to contact this person?

Yes

Third Reference

First Name

Last Name

Phone Number

Relation to applicant

Is it okay to contact this person?

Yes

Medical History

Name of applicant's primary physician:

Physician's phone number:

Physician's address:

Please list other specialists who are treating the applicant.

Is the applicant on any regular medications?

Yes

Medication Details

For all regular medications, please list name, dosage and frequency, prescription date, and name of prescriber.

Please describe the purpose for each of the medications listed above.

Has the applicant ever received psychiatric care?

Yes

If so, please describe the nature of the issue, the treatment, and whether they are still receiving psychiatric care?

Allergies

Is the applicant allergic to any medications?

Yes

If so, please list:

Is the applicant allergic to foods, pollens, animals, insect bites, skin contacts, substances, etc.?

Yes

If so, please describe these allergies and the treatment that is usually necessary:

Does the applicant have any dietary restrictions?

Yes

If so, please list:

Conclusion

If there is any further information which could influence the care, health, or well-being of this individual at Hilltop Ranch, please explain:

Do you certify that, to the best of your knowledge, the provided information is true and accurate?

Yes

Apply to live at Hilltop Ranch

Please be as honest as possible as you answer these questions; ultimately, a poor match isn't in anyone's best interest. Let us know if you have any questions as you complete the application. Once you've submitted your application, we will be in touch to discuss next steps within one week.

NOTE: Depending on how long you spend on your application, this page may time out. For best results, complete the longer responses on a separate document and then copy and paste here when you're ready to submit.

Applicant Information

Primary Guardian Information

Secondary Guardian Information

Help us get to know the applicant

References

Second Reference

Third Reference

Medical History

Medication Details

Allergies

History of illness, hospitalization, and/or surgery

Conclusion

Want to live at Hilltop Ranch?

Our application is now live.

We currently have a few spots remaining. Once all eight spots are filled, new applicants will be added to our waitlist.