Questionnaire For HSCL Wait-List
Please complete form to submit to wait list committee. You will be notified after review process.
Name of Prospective Resident *
Contact Name *
Contact Phone Number *
Contact Email *
Contact Address- used only for wait list purposes. *
How did you hear about us
Clear selection
If other please explain
Desired Move-In Time
Clear selection
What is the age of the prospective resident? *
Briefly Describe Care Needs *
Payment Type- Upon admission, what payer source can you anticipate? *
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