Keene Valley Neighborhood House - Assessment
Looking for the proper care for your loved one can be overwhelming. And expensive. We are here to help. In certain circumstances, financial assistance may be available. By answering a few questions, we can assess if the Neighborhood House is the right place for your loved one - physically, emotionally and financially. 
Name of person completing form: *
Email address of person completing application *
Phone number (optional)
Name of applicant (potential resident):
Age of applicant: *
Marital Status *
Column 1
Married
Single
Divorced
Widowed
Partner
US Veteran? *
Column 1
Yes
No
Is the applicant the widowed spouse of a US veteran? *
Column 1
Yes
No
If the applicant is a US veteran, or the widowed spouse of a US veteran, what years did the veteran serve?
Health Insurance - select all that apply: *
Required
Mobility of applicant: *
Cognitive abilities of applicant: *
Vision of applicant: *
Hearing of applicant: *
Does the applicant need or use any of the following medical equipment? (select all that apply): *
Required
Income and other resources available to help cover the cost of care (please note that we customize our rates based on the applicant's resources) - select all that apply: *
Required
Total income per month (social security, plus pension, plus dividends, etc.) *
Total amount of savings (enter "0"  or "none" if no savings are available): *
Total value of property or other assets (enter "0" or "none" if there are no assets available): *
Preferred contact method: *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms