The Mane Haven Intake Form 
Welcome to The Mane Haven . This form helps us get to know you and ensure we provide a safe, comfortable and supportive living environment that meets your individual needs. Please complete all sections accurately. All information will remain confidential.
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Full Name:
Date of Birth:
Gender:
Phone Number:
Email Address:
Current Address:
Emergency Contact Name: 
Relationship:
Phone Number:
Health & Medical Information 
In case of an emergency we will know whom to contact
Primary Physician:
Physician Phone:
Medical Conditions:
Medications (List All):
Allergies:
Clear selection
Mobility Needs:
Dietary Restrictions:
Personal Preferences & Lifestyle 
Preferred Daily Routine (wake-up/sleep times, activities:)
Hobbies/Interests:
Smoking:
Clear selection
Pets:
Clear selection
Religious/Spiritual Preferences:
Support Services Needed:
Financial Information
How will you be providing funding for your stay:
What date do you relieve your payment: 
How much funding do you receive:
Acknowledment
I certify that the above information is accurate and complete to the best of my knowledge.
Resident/Representative Signature:
Date:
MM
/
DD
/
YYYY
Saff Intake Completed By:
Date: 
MM
/
DD
/
YYYY
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