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Questionnaire

are you a good fit?

We welcome individuals who are 18 years of age or older, regardless of race, religion, or
national origin. Those who find Rochelle Home to be a good fit have a certain level of independence in personal care needs, ambulation and safety awareness. Please fill out the form below.

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: 64 MB.
Is the Applicant filling out this form?(Required)
Name
Address
Please Note: Rochelle Home 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.