Intake | Care and Keeping

Pre-Intake & Disclosure

Please take a moment to fill out the form.

First Name

Last Name

Phone

Are you submitting this for yourself or on behalf of someone else? If you are submitting for someone else, please include their full name below.

Birthdate

Height

Weight

Primary Care Physician

Immediate Health Concern and Diagnosis

Current Living Situation

Allergies

Is there Power of Attorney and/or Advanced Directive in place?

Are you or the person you are helping receiving Medicaid funding? Is there a need for Medicaid in the future?

Is there anything else you would like us to be aware of prior to meeting with you?

View, Download & Print Disclosure Form

I have received and read a copy of the Long Term Care Referral Agent Disclosure and Advisory Form, and agree to the terms & conditions

Thanks for submitting!

Disclaimer

HB 2661 requires referral agents to have background checks prior to having direct contact with clients.

In addition, a referral agent may not share or sell a client’s placement information to a facility or marketing affiliate without obtaining affirmative consent from the client for each instance of sharing or selling this information.

Pre-Intake & Disclosure

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