Residential Application

This application takes 1-2 hours to complete. Please be sure that you have all of your documentation at the time of starting the application and complete in one sitting.

After submitting the application, you will be required to upload the following materials within 48 hours:
- Recent psychological report
- Applicant photograph
- Medical history
- Behavioral evaluations/modification plans (if applicable)
- Current service plan (if applicable) If you have any technical issues, please contact marketing@umarinfo.com.

Person submitting application*

First Last Relationship to Applicant

Resident Information

Name*

First Middle Last Preferred Name

Gender*

Date of Birth*

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone*

Type of Placement*

Which area are you applying for?*

If you selected 'Other', please explain

What has caused you to seek residential placement at this time?*

Please identify services that are needed for the applicant to stay in his/her residential placement.*

Family Contact Information

Parent Name*

First Middle Last

Parent Email*

Parent Home/Cell Phone*

Parent Work Phone

Parent Address (If different from above)

Street Address Address Line 2 City State ZIP Code

Emergency Contact*

First Last

Emergency Contact Address*

Street Address Address Line 2 City State ZIP Code

Emergency Contact Email

Emergency Contact Home Phone*

Emergency Contact Work Phone

Referral Data

Case Manager/Other Individual

Agency Name (if applicable)

Program or Contact Address*

Street Address Address Line 2 City State ZIP Code

Relationship to Applicant*

If you selected 'Other', please explain

Legal Guardianship Status

Legal Guardian Name

First Middle Last

Type of Guardianship (If Applicable)

County of Adjudication

Date of Adjudication

Legal Guardian Address

Street Address Address Line 2 City State ZIP Code

Legal Guardian Email

Legal Guardian Home Phone

Legal Guardian Work Phone

Medication Name	Dosage and Frequency	Route	Purpose of Medication	Compliance Issues

	Not an Issue	Mild	Moderate	Severe
Cries/Screams Excessively
Excessive Anger
Excessive Lying
History of Running Away
Inappropriate Sexual Behavior
Physically Assaultive
PICA/Attempts to Eat Inedibles
Property Damage
Self Injurious
Self Stimulation
Steals
Verbally Assaultive

Real Estate	Real Estate Value	Other Property	Other Property Value

Residential Services Application

Step 1 of 5

Resident Information

Family Contact Information

Referral Data

Legal Guardianship Status

Diagnoses - DSM V

Axis I - Primary Diagnosis

Axis II - Personality Disorder

Axis III - General Medical Conditions

Axis IV - Psychosocial and Environmental

Axis V - Global Assessment of Functioning (GAF Score)

Physical Health Care

Mental Health

Vision, Hearing, and Dental

Current Applicant Services

Independent Living Abilities

Social History

Financial Information

Insurance Information

Certification

Applicant Statement

Required File Uploads

ABOUT US

RESIDENTIAL

DAY PROGRAMS

VOCATIONAL

QUICK LINKS

5350 77 CENTER DR. SUITE 201 CHARLOTTE, NC 28217 | 704.659.7636

Date	Reason	Location

Where	When

Where	When

Source of Income	Monthly Amount