Application for Residency

Assisted Living or Memory Care?*

Assisted Living
Memory Care

Diagnosis of Dementia or Alzheimer's?*

Yes
No

Which one?*

Dementia
Alzheimer's

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Birthday*

MM

DD

YYYY

Gender*

Male
Female

Primary language

Marital Status*

Current or former occupation

Is there anyone helping you with your application?*

Yes
No

If so, may we contact them?*

Yes
No

(If Resident will be on Memory Care, this is the responsible party)

Name*

Relationship*

Address*

Phone*

What is your current living situation?*

Do you own a car?*

Yes
No

Do you intend to bring it?*

Yes
No

Do you drive yourself regularly?*

Yes
No

Who helps you at home?*

How do they help you?*

Do you have any services to assist you at home? If so, what service agencies and the types of assistance do they provide?*

What is the reason you are considering supportive housing?*

Are you currently in a Skilled Nursing Facility/Rehab?*

Yes
No

If so, why?*

Name of Facility*

Daily Living

Physician's Name*

Phone Number*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

What medical/health problems do you have?*

What medications are you currently taking?*

Do you use oxygen?*

Yes
No

Do you require assistance/reminders to administer your medication(s)?*

Yes
No

Do you require assistance with a special diet or eating?*

Yes
No

If so, describe:

Do you smoke?*

**WE ARE A TOBACCO FREE CAMPUS**

How do you enjoy spending your time? What hobbies do you enjoy?*

How often do you use a computer or tablet?*

Do you have a pet that you intend to bring? If so, what type?*

We have a 15-pound weight limit.

Please check the task(s) you need assistance with:

Do you use an assistive device? If so, what?*

If you use a wheelchair, can you transfer in and out of it on your own?

Yes
No

What other assistance do you feel you need?

Long Term Care Insurance

Do you have a long-term care policy that cover Assisted Living/Memory Care?*

Yes
No

If yes, list company and policy*

Deposit

Deposit to hold a Suite is $1,500.00.

Please make check payable to:
Ocean Springs Senior Management, LLC

Please mail check to:
Lighthouse Assisted Living and Memory Care
Attention: Beth Joachim
8905 Ocean Springs Road
Ocean Springs, MS 39564