Assisted Living Application Step 1 of 15 - Primary Application Contact 0% Primary ContactPerson completing this form will be the primary contact for any questions regarding the resident application.Primary Contact Name(Required) First Last Primary Contact Phone Number(Required)Primary Contact Email(Required) Resident InformationResident Full Name(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Middle Last Resident Phone Number(Required)Resident Current Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Social Security Number(Required)Place of Birth(Required)Date of Birth(Required) MM slash DD slash YYYY Marital StatusMarriedSingleSeparatedDivorcedWidowName of Spouse First Last If deceased, date of death MM slash DD slash YYYY In Case of Emergency NotifyName First Last RelationshipAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Contact for Billing InformationName First Last RelationshipAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Name of Long Term Care Insurance CompanyPolicy NumberHousing PreferenceOne-bedroom ApartmentEfficiency Apartment ASSISTED LIVING MONTHLY RATE SHEET ONE BEDROOM APARTMENT SECOND PERSON Level 1 $3,950.00 $1,650.00 Level 2 $4,500.00 $2,200.00 Level 3 $4,850.00 $2,650.00 EFFICIENCY APARTMENT (One person only) Level 1 $3,350.00 Level 2 $3,950.00 Level 3 $4,500.00 Includes: 24 hour emergency response system Includes a pull cord in the bathroom and 1 pendant per tenant 24 hour staffing Two delicious home cooked meals prepared daily in the Westhaven Kitchen Variety of planned activities and social programs Paid Utilities, individually controlled heat and air conditioning (telephone not included) Mediacom Family Cable Housekeeping and Maintenance Services Beautifully decorated Dining and Common Areas *A Functional Assessment, Health Assessment, and Cognitive Assessment will be completed prior to admission to determine Personal Service Level. *A copy of the Occupancy Agreement is available upon request. AssestsCashAccounts ReceivableBank AccountsStocks/BondsHomeOther Real EstateCash Value of Life InsuranceOther AssetsTotal Assets LiabilitiesNotes PayableMortgage on HomeOther LiabilitiesTOTAL LIABILITIES MONTHLY INCOMEReal Estate RentalsInvestmentsSocial SecurityAnnuitiesPensionsTrust FundOther SourcesTOTAL MONTHLY INCOMEThe applicant further agrees and promises to maintain at a minimum in the future his/her present approximate financial position with regard to the ability to pay for Independent Living services. If the applicant significantly reduces his/her financial position so that he/she may no longer have the ability to pay, then the applicant understands and agrees that this change will justify Westhaven in then refusing or turning away the applicant from admission to Westhaven Independent Living. Education BackgroundProfession/Career:HobbiesAre you a Veteran? Yes No Are you a Veteran’s Spouse? Yes No Military ExperienceIf a Veteran, do you currently receive VA Meds? Yes No Do you plan on using VA Meds in Assisted Living? Yes No Are you eligible for or receive other VA benefits? Yes No Church AffiliationName of ChurchAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Minister First Last Phone number of Minister Person Responsible for Funeral ArrangementsName First Last Funeral Director to be calledAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Nursing Home PreferenceName First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Documents Upload Drop files here or Select files Max. file size: 128 MB, Max. files: 10. The following documents are needed in order to complete the application process. You can either submit them now online or bring them with you in person. Document List: ID Insurance Cards POA Paperwork Living Will Date MM slash DD slash YYYY Signature
