---
title: Residential Dementia Care Application Form Template | Paperform
description: Professional application form for memory care facilities to assess dementia patients' cognitive function, wandering risks, and care needs. Includes cognitive scoring and behavioral evaluation.
url: "https://paperform.co/templates/residential-dementia-care-application-form"
type: static
generatedAt: "2026-03-28T00:45:02.760Z"
---

[← Back to free form templates](/templates/)    ![Residential Dementia Care Application Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/residential-dementia-care-application-form.png)
    [Preview](https://_preview.paperform.co/ai-template/residential-dementia-care-application-form) [Use this template for free](/create?ai-template=residential-dementia-care-application-form)    [Application Forms](/templates/category/applications/) [Healthcare](/templates/industry/healthcare/)[Senior Care](/templates/industry/senior-care/)[Assisted Living](/templates/industry/assisted-living/) [Nurse](/templates/role/nurse/)[Social Worker](/templates/role/social-worker/)[Healthcare Administrator](/templates/role/healthcare-admin/)[Caregiver](/templates/role/caregiver/)     About this free form template
### Streamline Your Dementia Care Admissions with Paperform

Finding the right residential care placement for a loved one with dementia is one of the most important—and emotionally challenging—decisions families face. For memory care facilities, gathering accurate, compassionate information during the application process is essential to matching residents with the right level of support and creating a safe, dignified environment from day one.

This **Residential Dementia Care Application Form** template helps dementia care facilities, assisted living communities, and memory care providers collect detailed resident information, assess cognitive function, evaluate wandering risks, and determine the appropriate level of memory care—all through a single, thoughtfully designed form.

#### Why Memory Care Facilities Need Purpose-Built Application Forms

Traditional housing applications weren't designed for the unique complexities of dementia care. Memory care admissions require:

 - **Detailed cognitive assessments** to understand the resident's current abilities and care needs
 - **Behavioral and safety evaluations** including wandering risk, aggression triggers, and supervision requirements
 - **Medical history and medication tracking** to coordinate with healthcare providers
 - **Family contact information** for emergency situations and care coordination
 - **Financial verification** for care costs, insurance coverage, and payment arrangements

This Paperform template brings all of these elements together in one professional, easy-to-complete application that can be filled out online by family members, caregivers, or facility intake coordinators—eliminating confusing PDFs, illegible handwriting, and missing information that can delay placement.

#### Built for the Realities of Dementia Care Admissions

This template includes condition-specific fields that matter most to memory care providers:

 - **Cognitive assessment scoring** to establish baseline function and care level
 - **Wandering prevention needs** with questions about elopement risk, spatial disorientation, and supervision requirements
 - **Memory care level determination** (early-stage, moderate, or advanced dementia support)
 - **Activities of daily living (ADL) evaluation** covering bathing, dressing, toileting, eating, and mobility
 - **Behavioral symptoms tracking** including agitation, sundowning, aggression, and sleep disturbances
 - **Medical conditions and medication management** with space for detailed notes on chronic conditions, allergies, and prescriptions
 - **Emergency contact collection** for multiple family members and healthcare proxies

The form uses **conditional logic** to show follow-up questions based on cognitive scores or behavioral indicators, keeping the application streamlined for families while capturing the depth of information your care team needs for proper placement decisions.

#### How Dementia Care Facilities Use This Template

**Memory Care Communities** use this form on their website to pre-screen applicants and gather essential information before the in-person assessment, reducing intake time and improving the quality of initial consultations.

**Assisted Living Facilities with Memory Wings** deploy this form to evaluate whether prospective residents need standard assisted living or specialized memory care, helping families understand care levels and associated costs upfront.

**Senior Care Placement Agencies** share this form with families to collect comprehensive information they can forward to multiple facilities, streamlining the search process during a stressful time.

**Healthcare Case Managers** use this form to document resident needs when coordinating transitions from hospital to memory care, ensuring continuity of care and complete handoffs.

#### Design That Respects the Application Process

Memory care applications are often completed by adult children navigating difficult emotions while managing complex logistics. This template uses Paperform's **doc-style editor** to create a form that feels approachable and compassionate rather than clinical and overwhelming.

You can customize the header with your facility's logo, add warm welcome text that acknowledges the difficulty of the decision, include photos of your community, and organize sections with clear headings that guide applicants through medical history, cognitive assessment, care needs, and financial information in a logical flow.

Choose between a **multi-page layout** that breaks the application into manageable sections (Resident Information, Medical History, Cognitive Assessment, Care Needs, Financial Information) or keep everything on one scrolling page for families who prefer to see the full picture upfront.

#### Automate Your Admissions Workflow with Stepper

Once a dementia care application is submitted, there's a lot that needs to happen: intake coordinators need to review the information, clinical directors need to assess care level, admissions teams need to schedule facility tours, and financial counselors need to verify insurance and payment options.

Instead of manually routing applications through email or spreadsheets, connect this form to **[Stepper](https://stepper.io)**—your AI-native workflow builder—to automate the entire admissions process:

 - **Trigger care level assessments** by routing high-priority applications (e.g., immediate placement needs, advanced dementia) directly to clinical directors
 - **Schedule facility tours** automatically by sending calendar invitations to families and availability to admissions coordinators
 - **Create resident profiles** in your facility management system or CRM with all application data pre-populated
 - **Notify care teams** via Slack or email when a new application matches their unit's specialization (e.g., memory care for Lewy body dementia, behavioral unit for aggression)
 - **Route financial verification** to billing teams with insurance details and payment preferences already attached

Stepper keeps your admissions pipeline moving efficiently while ensuring nothing falls through the cracks during the critical transition period.

#### Secure, Compliant, and Family-Friendly

Dementia care applications contain sensitive health information that requires careful handling. Paperform is **SOC 2 Type II compliant and GDPR-ready**, with secure data handling, SSL encryption, and configurable data retention policies that align with healthcare privacy best practices. While Paperform is not HIPAA compliant, it provides robust security measures appropriate for pre-admission screening and intake processes.

You can customize confirmation pages to provide families with immediate next steps—what to expect after submission, timeline for review, contact information for questions—reducing anxiety and improving the application experience during an already stressful time.

#### Who This Template Is For

This Residential Dementia Care Application Form is ideal for:

 - **Memory care facilities** assessing prospective residents for specialized dementia units
 - **Assisted living communities** determining appropriate care levels for residents with cognitive decline
 - **Senior care placement agencies** gathering comprehensive information to match families with suitable facilities
 - **Geriatric care managers** coordinating admissions and transitions for clients with dementia
 - **Adult family homes** specializing in dementia care and needing detailed intake documentation
 - **Continuing care retirement communities (CCRCs)** managing transitions from independent living to memory care

#### Start Accepting Better Applications Today

With Paperform's **30,000+ designer templates**, you can customize this dementia care application to match your facility's brand, care philosophy, and specific services. Add your logo, adjust the cognitive assessment questions to align with your clinical protocols, include facility-specific policies, and create a professional application experience that reflects the quality of care families can expect.

Whether you're a single memory care home or a multi-facility senior living organization, this template gives you a compassionate, comprehensive starting point for gathering the information you need to provide excellent dementia care from day one.

Get started with Paperform today and transform your dementia care admissions process into a streamlined, family-friendly experience that honors both the complexity of the decision and the dignity of every prospective resident.
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