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ABOUT US
Our Philosophy
Who We Are
FAQs
Testimonials
LIVING HERE
Living With a Purpose
The Admission Process
Daily Life
CARE
Our Care Team
Visiting Specialists Program
Memory Care
Services
RESOURCES
Partner Organizations
News
CONTACT
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Application For Admission
ENQUIRER'S CONTACT INFO
Name
City
Address
Province
Preferred Contact Number
Preferred Time Of Day to be Contacted
Email
POTENTIAL RESIDENT'S PROFILE INFO
Name of Potential Resident
Date of Birth *
Current Address
Current City/Town
Prov
Postal Code
Telephone
Currently residing
Alone
With spouse
With other caregiver
In a retirement residence/nursing home
How did you hear about us? (Please select all that apply)
Website
Newspaper
Radio/TV Ad
Word of Mouth
Other
POTENTIAL RESIDENT'S PROFILE INFO
1. Getting dressed
Yes
No
2. Bathing/showering
Yes
No
3. Personal grooming/hygiene
Yes
No
4. Mobility/Gait/Balance
Yes
No
5. Mobility Devices (Please Check)
Yes
No
6. Toileting or continence care
Yes
No
7. Other Needs (e.g. glasses, hearing aid, etc. (please describe)
8. Primary languages Spoken (list)
9. Does Resident smoke?
Yes
NO
if yes, amount per day
10. Does Resident drink alcohol?
Yes
NO
If yes; amount and frequency
SUBMIT APPLICATION
