Intake Form

Our program is designed for individuals who are capable of living independently. This is not a personal care home, nursing home, or assisted living facility. We do not provide medical care, personal assistance, or 24/7 in person supervision. You must be able to manage your own: Personal hygiene and grooming; Meal preparation and eating; Medication (unless managed by an outside provider); Mobility and transportation arrangements; Housekeeping and laundry; Daily living responsibilities. If you require medical or personal care services, they must be provided by a licensed outside agency or caregiver, arranged and paid for separately.

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications amRadioong others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

Medical History

Legal Background

Income Information

Housing Preferences

Independent Living & Functionality Acknowledgment

I certify that the above information is true to the best of my knowledge. I understand that this intake does not guarantee placement, and my application will be reviewed by staff.

Documentation