New Jersey Department of Human Services

Adult Day Services Program for Persons with Alzheimer's Disease or Related Disorders

PO Box 807

Trenton, NJ 08625-0807

WAITING LIST APPLICATION

AGENCY INFORMATION
Name

Telephone Number

CLIENT INFORMATION
Client Name

Age

Yearly Income

Requested Funding Start Date

Requested Number of Days Per Week

Marital Status

Married

Single	Living Arrangement

Alone	With Other Family Member

With Spouse	With Other Non-Paid Caregiver
Dementia-Related Diagnosis

Alzheimer’s	Multi-Infarct	Other (Specify):

SDAT	Vascular
Probable Alzheimer’s	Parkinson’s
Status of ADL’s

Independent	Moderately	Moderately	Dependent

Independent	Dependent
Deterioration of Cognitive Abilities

Minimal	Moderate	Severe
CAREGIVER INFORMATION
Relationship to Client:

Spouse	Son/Daughter	Other Relative	Friend
Living With Client

Yes	No
Currently Employed

Full Time	Part Time	Not Employed
Health Status

Excellent	Good	Fair	Poor
Assistance from Other Family Members

Yes	No	Occasionally

CSS-10

JUL 12

CSS-10, Waiting List Application

CSS-10, waiting list application, division of aging services, DAS

2004-07-06

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human services