BethHaven Incorporated Wait List

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BethHaven is an Assisted Living Facility for Adults with Mental Illness

Email *

What is the name of the individual looking for housing?

What gender is the applicant?

Male

Female

Other:

Clear selection

What is the name of the individual filling out this form?

How are you related to the applicant?

Self

Parent

Sibling

Other Family Member

Case Manager

Other:

Clear selection

What is your best contact number?

What is the applicant's Mental Health Diagnosis?

Does the applicant have any medical needs?

What is the applicant current living situation?

Living Independantly

Living with Family

Living in a supported environment

Homeless

Other:

Clear selection

Does the applicant have income?

Social Security

Employment Income

VA Benefits

No Current Income

Other:

What insurance does the applicant have?

Medicaid

Medicaid Long Term Care

Medicare

Private Insurance

Other:

Does the individual:

Yes

Currently see a psychiatrist?

Currently take medications

Have any ongoing legal issues

Have a history of aggression/violence

Clear selection

Any comments on the above responses?

When was the applicant's last hospitalization?

Any other comments or things to include?

Once you submit, the applicant will be added to our waitlist. Administrative staff will reach out within the next week. BethHaven is a smaller assisted living, so immediate placement does not happen very often.

Please reach out to the office at (719) 632-5920 or info@bethhaveninc.org if you have any questions or would like to set up a tour.

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