LIFEHOUSE APPLICATION FOR CARE
Please take a moment to fill out all of the information below. Our Care Team takes a “mind-body-spirit-emotion-environment” approach to the practice of traditional medicine and care. Once we receive this application, one of our team members will contact you within 2 weeks of submitting your application.
PRIMARY CONTACT INFORMATION
RELATIONSHIP TO APPLICANT *
ARE YOU THE APPLICANTS POWER OF ATTORNEY and/or POWER OF CARE? *
Required
YOUR FIRST NAME *
Your answer
YOUR LAST NAME *
Your answer
YOUR EMAIL *
Your answer
YOUR PHONE NUMBER *
Your answer
PERSONAL INFORMATION FOR APPLICANT
FIRST NAME *
Your answer
LAST NAME *
Your answer
GENDER *
WHAT COMMUNITY DOES APPLICANT CURRENTLY LIVE IN? *
Your answer
IS THE APPLICANT CURRENTLY RECEIVING MEDICAL CARE SERVICES? *
IF YES, HOW MANY HOURS PER WEEK *
APPLICANTS AGE *
APPLICANTS MOBILITY *
Required
APPLICANTS CARE NEEDS
PLEASE SPECIFY APPLICANTS CURRENT LIVING SITUATION *
WHEN WOULD THE APPLICANT WOULD LIKE TO MOVE IN: *
PLEASE SELECT THE SERVICES YOU ARE INTERESTED IN: *
Required
CARE WISH LIST *
Please let us know the support you are hoping for:
Your answer
AVAILABILITY
PREFERED TOUR (MEET & GREET) DATE *
Please let us know the day that would work best for you to come visit our Healing Home:
Required
PREFERRED CALL TIMES *
Please let us know the best time to call you:
Required
Please check Yes below to confirm we have permission to contact you: *
Required
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