Assisted Living and Memory Care
228-215-0521
8905 Ocean Springs Rd • Ocean Springs, MS 39564
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Application for Residency
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Application for Residency
Assisted Living or Memory Care?
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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
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Married
Single
Widow/er
Divorced
Separated
Current or former occupation
Is there anyone helping you with your application?
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Yes
No
If so, may we contact them?
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Yes
No
(If Resident will be on Memory Care, this is the responsible party)
Name
*
Relationship
*
Address
*
Phone
*
What is your current living situation?
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Do you own a car?
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Yes
No
Do you intend to bring it?
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Yes
No
Do you drive yourself regularly?
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Yes
No
Who helps you at home?
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How do they help you?
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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?
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Are you currently in a Skilled Nursing Facility/Rehab?
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Yes
No
If so, why?
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Name of Facility
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Daily Living
Physician's Name
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Phone Number
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Address
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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?
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Do you use oxygen?
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Yes
No
Do you require assistance/reminders to administer your medication(s)?
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Yes
No
Do you require assistance with a special diet or eating?
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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?
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How often do you use a computer or tablet?
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Do you have a pet that you intend to bring? If so, what type?
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We have a 15-pound weight limit.
Please check the task(s) you need assistance with:
Preparing Meals
Eating/Feeding Self
Walking
Housekeeping
Laundry
Bathing
Dressing
Grooming
Oral Care
Safety due to poor judgement
Finances
Shopping
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