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SILVERCREEK AFH
Intake Form
First name
*
Last name
*
Phone
*
Email
*
Name of Resident
*
Relation to Resident
*
Age of Resident
*
Weight of Resident
*
Height of Resident
*
Gender of Resident
*
Do you have an RN assessment?
*
Yes
No
How did you hear about us?
*
Relevant Medical History
*
Reason for moving into an adult family home
*
Eating
*
Personal Hygiene
*
Mobility
*
Transferring
*
Bathing
*
Toileting
*
Memory Issues
*
Medication Administration
*
Behaviour
*
Skin Issues
*
Current Living Condition
*
Funding Source
*
Private Pay
Medicaid on Admission
Medicaid Spend Down
Other
For Medicaid Spend Down, what is the estimated number of months prior to Medicaid conversion.
Other information you want us to know
Target Move in Date
*
Month
Month
Day
Year
Would you like a summary of disclosures of our rates and services, including itemized services?
Yes
No
Any questions for us?
Submit
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