Resident Information Sheet
Professional Resident Information Sheet template for Adult Family Homes. Includes editable Word (.docx) and printable PDF formats.
[YOUR ADULT FAMILY HOME NAME HERE]
Resident Information Sheet
TEMPLATE • Inspection-Ready AFH Standard
1. Resident Personal & Demographics Summary
This agreement is entered into on this _____ day of ____________, 20___, between [ADULT FAMILY HOME NAME] (Provider) and [RESIDENT / POA NAME].
2. Emergency Contact & Guardian Details
FINANCIAL TERMSBase Rate & Payment Schedule: Resident agrees to pay Provider a monthly base fee of $______ payable in advance on the first (1st) day of each calendar month.
3. Primary Care Physician & Pharmacy Information
Provider Signature / Date
Resident / POA Signature / Date
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Document Section Breakdown (4 Sections)
Resident Personal & Demographics Summary
Full legal name, preferred name, DOB, SSN, primary language, and religious preferences.
Emergency Contact & Guardian Details
Primary/secondary POA contacts, legal guardian papers, and financial guarantor info.
Primary Care Physician & Pharmacy Information
Doctor name, clinic address, phone, preferred hospital, and contracted pharmacy.
Allergies, Diagnoses & Mobility Overview
Known allergies, primary medical diagnoses, transfer assistance level, and diet type.
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