Adult Day Services

Posted December 22nd, 2008 by bettina

The Adult Day Services program at Maristone Senior Living All Maristone Communities offer the "MariCare" our Adult Day Services (or ADC's) option. It is designed to provide care and companionship for seniors who need assistance or supervision during the day. The program offers relief to family members or caregivers and allows them the freedom to go to work, handle personal business or just relax while knowing their relative is well cared for.

The Maristone Adult Day Services are available Monday thru Friday. Breakfast and Lunch are included along with an afternoon snack. The Maristone Communities offer the exclusive MariCare program on an application only basis. To obtain an application and request an interview, please contact us.

c/o The Maristone of Franklin

1031 Riverside Drive

Franklin, Tennessee

Phone: Fax:

E-Mail: Adult Day Care

Family and Personal Information

Full Name:

Address:

Telephone Number:

Date of Birth:

(dd/mm/yy)

Place of Birth:

Marital Status:

Married

Single

Divorced

Widowed

Name of Husband or Wife, if still living:

With Whom does the Applicant Live?:

Your Children - Child 1:

Address - Child 1:

Work Telephone - Child 1:

Home Telephon - Child 1:

Name of Emergency Contact:

Name and address of next nearest relative or trusted friend who could be contacted in an emergency:

Address of Emergency Contact:

Name and address of next nearest relative or trusted friend who could be contacted in an emergency:

HomeTelephone Number of Emergency Contact:

Name and address of next nearest relative or trusted friend who could be contacted in an emergency:

Work Telephone Number of Emergency Contact:

Name and address of next nearest relative or trusted friend who could be contacted in an emergency:

Health History:

Physician 1 Name:

Physician 1 Address:

Physician 1 Telephone:

Choice of Hospital:

Pharmacy Name:

Pharmacy Telephone:

Medicare # Part A:

Medicare # Part B:

Other Insurance Coverage:

Assistance in Other Areas:

	None	Other	Explain
Walking, Standing
Toileting
Bathing
Eating

What assistance (if any) is required in the following areas?

Assistance Explanation:

If you checked "Explain" above, please explain what other assistance you may need.

Dietary Requirements:

Regular Diet

Low Sodium

Diabetic

Other Dietary Requirements:

Current Medication #1:

Dosage of Medication #1:

Times Medication #1 is Given:

Supervision Required:

Yes

Explain (if yes):

Starting Date:

(One month minimum required)

Frequency:

Transported by:

Town

Family

Other

Assistance Required:

Special Needs:

Agency Name:

Name, Address and telephone number of individual or agency responsible for payment of Adult Day Care services:

Agency Address:

Agency Telephone:

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