Residence Request Form

*Red fields are required to submit a request.

Residence Information

Facility Name:

Contact Person:

Address:

City:

State:

Zip Code:

Telephone No.: Format: xxx-xxx-xxxx

License No.:

Max Number of Residents:

Hospice Waiver:

Dementia Waiver:

Type of Facility

(Please select all that apply)

Residential Care Home	Assisted Living Facility
Short Term Care	Skilled Nursing Facility
Senior Community	In-Home Care
Hospice Care	Adult Day Care/Respite Care
Other

Cognitive Status

(Please select all that apply)

Accept Clients with Alzheimer's/Dementia	Alzheimer's Special Care Unit
Accept Clients with Mental Disabilities	Accept Alcoholics

Services Available

(Please select all that apply)

Short term feeding assistance	Night time assistance
Bathing, dressing, and grooming	Transportation service
Diabetic Diets	Housekeeping and laundry service
Medication Management	Staff awake at night
Wheelchair transfer assistance

Special Needs Offered

(Please select all that apply)

Insulin injections	Pets
Urinary catheter	Accept smokers
Oxygen

Please provide any other relevant information.