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Our Staff
Our Story
Our CEO/Founder
Our Staff
Programs
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The UCMJ Adult Day Activity Center
Behavior and Personality Traits
Behavior: please check all that apply
Confusion about current eventsin their life, confusion about time and place
Problems with judgment: making important decisions, can’t handle major life decisions
Difficulty concentrating on a task or activity
Takes little or no interest in activities and will not start them by self
Becomes anxious in noisy environments Hoards objects
Wanders away from home
Wears a Medic Alert or ID bracelet
Cannot be left at home alone, must be supervised
Requires constant attention and will not let you out of sight
Becomes verbally aggressive
Becomes physically aggressive
Becomes anxious
Engages in embarrassing and socially inappropriate behavior.
Talks to people he/she does not know
Denies or seems unaware that anything is wrong
Reports seeing or hearing things that are not there
Has episodes of paranoia
Appears depressed
Afraid of dogs
Engages in behavior that is potentially dangerous to self or others
Please list any other behaviors/habits or challenges that would be helpful for us to know.
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Personality: Current patterns of relating to others
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Personality: Does the applicant read?
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Personality: Does the applicant write?
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Favorite things/Preferences and Life Experiences: (Please note; this information will help us to understand and share conversation with the applicant.)
Place of Birth
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Places applicant lived as a child and as an adult:
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Memories/activities most often talked about:
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Highest level of education
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8th grade
High School
College
Other
Veteran
Yes
No
If yes, please list Service, Branch, and Rank
Eligible for VA benefits
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Brief work history (places of employment, types of jobs, age of retirement, etc):
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Names of children and the most important people in the applicant’s life:
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History of alcohol/drug abuse:
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History of traumatic events (abuse, war, tragedy, abandonment):
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History of brain trauma:
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Personal Interests:
Favorite vacations:
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Faith-based habits/rituals/beliefs that would be important for us to know (religious affiliation):
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Faith-based activities and/or community service work:
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Hobbies/Interests:
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Art Experiences/Talent:
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Music Experiences: Did/does the applicant play an instrument? Sing in a group? Play in a band? Dance? Other?
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What music did they and/or do they like to listen to? Favorite song(s)?
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Favorite reading materials, poems, stories, authors, magazines, etc.?
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How does the applicant currently spend their time during the day?
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What is special about this applicant that you would like us to know?
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Name of Person filling out form
*
Date
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Day Program
About Us
Services
Amenities
Hours of Operations
Reviews
Enroll Now
FAQ
About Us
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Our CEO/Founder
Our Staff
Programs
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Employee Resources
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Careers
Sponsor
Sponsorship Oppurtunities
SEED Funders
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Contact Us
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