Ollie's Place Specialty Suites
Senior Application
1. Basic Information
Applicant Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name
*
First Name
Last Name
Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
2. Living Preferences
Do you prefer a standard or premium room?
*
Standard
Premium
Interested in participating in wellness/educational programs?
*
Yes
No
3. Health & Wellness Questionnaire
Check all that apply:
*
Diabetes
High blood pressure
Stroke history
Arthritis or mobility limitations
Hearing impairment
Visual Impairment
Cognitive concerns
Medication assistance
Other - please specify
Do you use assistive devices
*
Cane
Walker
Wheelchair
None
Can you manage your personal care independently?
*
Yes
With minimal help
No
4. Medical Support
Primary Care Physician
*
Preferred Pharmacy
*
Need transportation to appointments?
*
Yes
No
5. Meal & Nutrition
Do you have dietary restrictions or food allergies?
*
No
Yes - please specify
6. Additional Notes or Concerns
Please type any additional notes or concerns you may have below.
7. Income & Insurance Information
Monthly Income Sources (check and list amounts):
*
Rows
Type of Income
Amount
Social Security
Pension/Retirement
SSI/SSDI
Other (please specify)
Total monthly income
*
Do you have health insurance?
*
Yes
No
If yes, check all that apply
*
Medicare
Medicaid
Private Insurance
Medicare Advantage
VA Benefits
Other
Insurance Provider(s)
Policy Number(s)
Primary Holder (if not applicant)
First Name
Last Name
Can you cover the monthly cost of $2,200–$2,900?
*
Yes
No
Not sure – I’d like to discuss options
8. Consent & Signature
I understand this application does not guarantee placement and is used to determineeligibility and best-fit services. I affirm that the above information is accurate to the best ofmy knowledge.
Please type full legal name as signature
Date
-
Month
-
Day
Year
Date
Submit
Submit
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