Home Away From Home Inquiry Form
                         COMPLETING THIS FORM DOES NOT GUARANTEE PLACEMENT                                                                             

Facility Fees

The monthly rental fee starts at $800.00 and will increase based on the level of care needed. Additionally, we require a one-time non-refundable security deposit of $300.00. The deposit can be paid in three installments of $100.00 each, added to the monthly rental fee for the first three months. There is also an additional fee of $200.00 added to all monthly rental payments for food expenses unless you receive SNAP benefits or a Health Food Card. If the food card benefits are less than $200.00 a month, the cash difference for the required monthly food contribution will be added to the monthly rental amount.

                                                        

                                                               A La Carte Service Packages
                                       All packages are services NOT included in the monthly rent.

Blue Package: $275.00 monthly
  • Medication reminders
  • Doctor visit reminders
  • Ordering prescription refills

White Package: $475.00 monthly
  • Medication reminders
  • Weekly laundry service
  • Doctor visit reminders
  • Ordering prescription refills
  • Grooming Assistance
  • Dressing
  • Bathing

Gold Package: $675.00 monthly
  • Medication distribution or Medication reminders
  • Weekly laundry service
  • Doctor visit reminders
  • Ordering prescription refills
  • Bathing
  • Dressing
  • Grooming assistance
  • Cooking meals
  • Light housekeeping
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Today's Date *
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Full Name (Individual completing this form) *
Phone Number (Individual completing this form) *
Email Address (Individual completing this form) *
Patient Full Name *
Patient  Date Of Birth *
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Patient diagnosis? *
Does the patient have violent behavior? *
Does the patient need assistance with daily living activities? *
Required
Patient Discharge Date? *
MM
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Does the patient have an ID / Drivers License? *
Do the patient have a checking account? *
If patient doesn't have a checking account how do they access their benefits? *
Can the patient afford to pay $800.00 a month rent? *
Will the patient be able and willing to contribute $200.00 a month for food? ( Contributions can be made in Cash, SNAP, or Food Benefit Cards) *
Do the patient have a Power Of Attorney or Payee? *
Required
Power Of Attorney or Payee contact information
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