How to complete this admission application:

To be considered for residence, the applicant must complete all pertinent sections of this online application with all required information included and submit. You can also download the form as a PDF and complete all pertinent sections offline, sign and date the application, and return it to:

Mary Mougey, Administrator
1200 North Avenue
Burlington, VT 05408

or email: mmougey@livingwellgroup.org

If the applicant has a guardian, the application must be signed by the guardian. Admission cannot be completed without a copy of the court order appointing the guardian.

If assistance is needed in completing this application, please call 802-658-1573.

    • Step 1: Personal Information

      All fields with "*" are required to successfully submit this application






      Sex*MaleFemale

      Marital Status*SingleMarriedWidowedDivorced

    • Step 2: Applicant's Contact Information




      Preferred Contact Method*PhoneAlternate PhoneEmail

    • Step 3: Relevant or Responsible Contact Information

      I am responsible for myself* YesNo





      Preferred Contact Method*Cell PhoneHome PhoneEmail

    • Step 4: General Information

      Primary Care Physician



      Do You Plan to retain this physician?* YesNo

      Do You handle your own business affairs?YesNo

      If no, who handles these affairs?




      Why would you like to be considered for admission to Ethan Allen Residence?

      What did you do for work most of your life?

      What are your interest/hobbies?

    • Step 5: Functional Assessment

      Please describe your current health issues:

      How do these issues impact your daily life?

      During the past six months, how many times have you seen a doctor?

      During the past six months, how many days were you so sick that you were unable to carry on your usual activities?
      NoneA Week or LessMore Then a Week

      During the past six months, were you in a hospital for health issues?
      YesNo

      If yes, how many days were you hospitalized?

      What sort of health issues were you hospitalized for?

      How would you rate your overall health at the present time?
      ExcellentGoodFairPoor

      How would you rate your overall health compared to a year ago?
      BetterAbout the sameWorse

      How much do your health issues stand in the way of your doing the things you want to do?
      Not at allA littleA great deal

      Do you have periods of confusion or forgetfulness that interfere with your daily activities?
      YesNo

      Please select all that apply to your mental status:
      ConfusedForgetfulDifficulty expressing selfWanderingSociableWithdrawnDepressionAnxiety


      Do you need assistance taking medications?YesNo

      If yes, please describe:

      Are you allergic to any medication or food?YesNo

      If yes, please describe any reactions you have experienced:

      Do you have any dietary restrictions?YesNo

      If yes, please describe

      Do you have any difficulty eating or drinking?YesNo

      If yes, please describe

      Do you use any of the following aids?
      WheelchairCaneWalkerGlassesContact LensesDenturesHearing Aid

      Other:

      How is your eyesight?
      ExcellentGoodFairPoorTotally Blind

      Other:

      Have you ever had a drinking problem or has your doctor ever advised you to cut down on drinking?YesNo

      Do you use tobacco/nicotine products including chewing tobacco?YesNo

      Do you use marijuana?YesNo

      Do you feel that you need medical care or treatment beyond what you are receiving at this time?YesNo

      If yes, please describe

      How well do you walk?
      AloneAlone with a cane, walker, etcOnly with the help of another personCannot Walk

      Do you have difficulty keeping your balance while walking?YesNo

      Is your sleep disturbed?YesNo

      How many hours a night do you usually sleep?

      Are you troubled by your heart pounding or by shortness of breath?YesNo

      Taking everything into consideration, how would you describe your satisfaction with life in general at the present moment?
      ExcellentGoodFairPoor

      How would you rate your mental or emotional health at the present time?
      ExcellentGoodFairPoor

      Compared to one year ago, how would you rate your mental or emotional health?
      BetterAbout the sameWorse

      How well do you use the telephone?
      Without helpWith some helpUnable to use telephone

      Do you cook meals for yourself?
      Without helpWith some helpUnable to cook meals

      Do you handle your own money?
      Without Help (write checks, pay bills, etc)With some help (manage day to day budgeting, but need help managin checkbook and paying bills)I do not handle my own money

      Are you able to feed yourself?
      Without help (able to feed yourself completely)With some help (need some cutting meat, etc)I am not able to feed myself

      Do you dress and undress yourself?
      Without help (able to select clothes, dress, and undress)With some helpI am not able to dress myself

      Do you take care of your own appearance? For example: combing your hair or shaving
      Without helpWith some helpI am unable to take care of my appearance

      How do you get in and out of bed?
      Without any help or aidsWith some help (either from a person or with the aid of a device)

      Explain:

      How do you bathe?
      Without helpWith some help (getting in and out of tub or shower or need special attachments)

      Explain:

      Do you ever have trouble getting to the bathroom on time?
      YesNo

      How often do you wet or soil yourself?
      Once or twice a weekThree times a weekNever

      Have there been any recent changes in care needs?
      YesNo

      If yes, please explain:

      During the past six months, have you had any help with things suck as shopping, cooking, taking medications, housework, bathing, dressing, and getting around?
      YesNo

      If yes, who is your major helper?


      Are you receiving any assistance from an outside agency, such as Home Health?
      YesNo

      If yes, please describe:

      Is religion important in your life?
      YesNo

      Do you have any religious beliefs potentially impacting your care?
      YesNo

      If yes, How often do you attend services and where?

      Is there anything else you would like us to know about your physical, mental, emotional, or spiritual health?

    • Daily Rate/Room and Board Information

      Those who receive ACCS or ERC Medicaid financial assist will be charged according to the Room and Board rules set by the Economic Services Division of the State of Vermont.

      The Private daily rate is a set amount per day. A tier worksheet is used to determine if an additional amount will be charged per month. This worksheet is done from an assessment of a resident’s care needs. This will be updated at least annually.

      Our facility may have some rates dependent on size of the room.

      Cost of cable service and telephone are not included in the daily rate or room and board charge.

      For more details, please speak with our Administrator.

    • Step 6: Financial/Insurance Information

      Do you have a bank trust department or other agent who manages your financial affairs?
      YesNo

      If yes, please provide:



      Have you assigned a Power of Attorney?
      YesNo

      If yes, please provide:



      Health Insurance


      Have you have long term care insurance?
      YesNo

      If yes, please provide:



      Do you have any other health, accident, or income protection insurance?
      YesNo

      If yes, please provide:



    • Step 7: Financial Statement

      Please provide accurate, honest, and complete information. This information will be kept strictly confidential.

      Monthly Income/Assets





      Do you own your own home?*
      YesNo



      Method of Payment* (check all that apply)
      Private PayPrivate InsuranceSSIChoices for Care

      If you selected "private pay", how long do you anticipate being private pay?
      0-6 months7-12 months13-24 months25-36 months36-48 months49+ months

      Choices for care eligibility is determinded by the State of Vermont, Medicaid Waiver Program eligibility and availability cannot be predicted or guaranteed.

    • Policies

      Pets:

      Ethan Allen Residence does not allow pets to reside in the Residence. Animals are welcome to visit at any time once appropriate vaccination records are provided.

      Personal motor vehicles:

      Personal motor vehicle policies vary by location. Please confer with the Residence’s admissions contact for more information.

      Smoking:

      Smoking policies vary by location. Please confer with the Residence’s admissions contact for more information.

      Discharge:

      It is the philosophy of Ethan Allen Residence for residents to remain at the Residence through end of life. However, there may be circumstances that do not allow this.

    • Release Form


      Current Mailing Address


      Legal Address (if different from mailing address)


      I hereby authorize Ethan Allen Residence, and its agents, to contact any individuals, Social Security, agencies, offices, groups, or organizations to obtain any information or materials deemed necessary to verify my suitability of eligibility for residence and services which I may require. I further authorize any of those contacted to release the information requested to Ethan Allen Residence and its agents.

      The information on this form is to be used by Ethan Allen Residence and its agents to assist in determining the eligibility and suitability of the applicant for residency at Ethan Allen Residence and identify appropriate services. We may be required to share financial and/or medical information with authorized state or federal entities upon written request.

      Statement of Applicant or legally authorized representative:

      I certify that all of the information provided on this form is true and complete to the best of my knowledge and belief.





      If a legally authorized representative has signed on behalf of the applicant, please attached documentary evidence indicating the extent and nature of this legal authorization.

    • Medical Release Form

      • 1200 North Avenue
      • Burlington, VT 05408
      • p 802-658-1573
      • f 802-497-1597
      • mmougey@livingwellgroup.org

      CONFIDENTIAL MEDICAL INFORMATION RELEASE AUTHORIZATION

      Name of Physician or other person(s) receiving release authorization



      I hereby authorize you to release to Ethan Allen Residence any information including diagnosis, medical records, treatments or examinations rendered to me while under your care.


      If Consenter used, please print name, address, and phone number



      Confidentiality Notice

      This document contains PRIVILEGED and CONFIDENTIAL information intended only for the use of the addressee(s) named above. If you have received this document in error, you are requested to destroy all documents. Thank you.

    • Submit Application


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