APPLICATION FOR RESIDENCY

Assisted Living or Memory Care?

Diagnosis of Dementia or Alzheimer's?

Gender:

Marital Status:

Is there anyone helping you with your application?

Do you own a car?

Do you intend to bring it?

Do you drive yourself regularly?

Are you currently in a Skilled Nursing Facility/Rehab?

What medications are you currently taking?

Do you use oxygen?

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

Do you require assistance with a special diet or eating?

Do you smoke?

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

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

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

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