Let us make you feel at home
Personal Information
Name *
Email *
Phone number *
Referral Source
How did you find out about us? *
Google
Facebook
Placement Agency
Friends and/or Family
Other
What is your relation to the resident? *
Resident Information
Resident's name *
Age *
Gender *
Male
Female
Prefer not to say
Other
Medical History
Relevant medical and surgical history *
Height *
Weight *
Reason for moving to an adult family home *
Do you already have an "RN Assessment for AFH"? *
Yes
No
Care Levels
Eating *
Independent
Needing Assistance
Dependent
Personal Hygiene *
Independent
Needing Assistance
Dependent
Bathing *
Independent
Needing Assistance
Dependent
Toileting *
Independent
Needing Assistance
Dependent
Mobility *
Independent
Needing Assistance
Dependent
Transfers *
Independent
Needing Assistance
Dependent
Medication Assistance *
Yes
No
Other Medical Information
Memory Issues *
Yes
No
Behavior
Skin Condition
Other information you want us to know
Living Situation
Current living situation *
Own Home
Relative's Home
Hospital
Adult Family Home
Senior Living
Other
Target move in date *
Would you like a summary of disclosures of our rates and services, including itemized services?
Yes
No
Do you have any questions for us?
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