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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
Other
Other information you want us to know
Target Move in Date
*
Month
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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