Sage Wood Assisted Living Services

Pre Admission Application
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Sage Wood Assisted living Services
P O Box 1175, 1192 Mount Silcox Drive
Thompson Falls, Montana
406-827-6111
Fax 406-827-6111
Visually Impaired Friendly Site

Just like Home, Only Better

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Pre-Admission Resident Application

Sage wood Assisted Living is a licensed assisted living Facility, nota a ‘nursing home” or
hospital. An assisted living Facility provides protected or supportive living arrangements for the elderly or other residents who need help with health maintenance tasks or desire personal care services. These services include room and board, help with activities of the daily living such as personal hygiene, dressing and grooming needs, assistance with medications, with an emphasis on memory care to support independence and dignity. While there is no licensed nurse on duty, registered nurses when needed are utilized through the resident’s third party benefits, such as Medicare, Medicaid or Private Insurance.

All residents must be able to recognize danger (e.g. fire) and be able to take life-saving action on their own initiative, being capable of exiting the building unassisted when warned by a signal or prompted.

Please complete the following information in order that we can determine if admission to Sage Wood Assisted Living Services can meet the specific needs of the applicant and to facilitate the highest level of personalized care for each resident. If you have any questions regarding the information being requested, please call me and I will be happy to go over it with you.

Sincerely, Barbara Larsen, Owner/Administrator

Resident’s Name:
Address:
Current Living Arrangements:
Problems with Current Living Arrangement:
Referred by:
Date of Birth:		Age:
Sex:		Marital Status:
Physician’s Name:		Phone number & Address:
Other Health or Social Services Providers:		Phone number & Address:
Date of last Dr.’s Visit:		Date of Last Hospitalization and why:
Family Member / Representative
Name:	Address:	Phone Number:	Relationship:
Name:	Address:	Phone Number:	Relationship:

Please list information about the resident’s health and social history that would be helpful to complete the required pre-move in assessment. This assessment will be completed within 30 days of moving to Sage Wood in order to determine if services can meet the heal maintenance and individual needs of the resident.

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