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Your Waiver / Intake Form

Date of birth
Month
Day
Year
Current Address
How did you hear about us?
Medical & Mental Health Information
Daily Living & Care Needs
Behavioral & Safety Screening
Financial Information
Medicaid Funding
SSI/SSDI
Private Pay
VA Benefits
County Funding
Insurance Provider
Monthly Income Source
Desired Move in Date?
Month
Day
Year

Use this To Upload Important Documents Such as

  • Psychological evaluation

  • Functional screen

  • Medication list

  • ID/insurance cards

  • Court orders

  • Discharge paperwork

  • Behavioral plans

  • Probation/parole paperwork

  • Guardianship documents

By signing this document, I acknowledge the inherent risks and voluntarily assume full responsibility for any injury, damage, or loss that may result from my participation. I hereby waive and release the business, its owners, and its staff from any and all liability, past, present, and future, relating to the services provided.

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Additional Details & Consent

To ensure we provide the best possible care, please provide any additional information regarding the resident's specific needs, dietary requirements, or daily routine preferences. Your thoroughness helps us create a personalized environment.

I hereby consent to the collection and processing of the health information provided above for the purpose of care assessment.

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