Resident Contract Agreement Information Form
Please complete this form so that a Resident Contract Agreement can be generated and sent to the relevant partties.
Resident Information
Resident Name
*
First Name
Last Name
Resident Date of Birth
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Care Home
*
Please Select
Beacon House
Croft Lodge
Estuary View
The White House
Willow House
Windward House
Person who will be completing the Resident Contract Agreement on behalf of the Resident
*
First Name
Last Name
Does this person hold LPOA?
*
Please Select
Yes
No
Their email address
*
example@example.com
Fee Information
How is the resident funding their care?
*
Please Select
Self-funding
Local authority
Date resident moving in
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
If respite care, planned date for resident to move out
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Will resident pay by Direct Debit
*
Please Select
Yes
No
Unsure at this moment in time
Agreed weekly fee (if NOT paying by Direct Debit)
*
If paying by Direct Debit, there will be a £25 weekly discount
Has the resident paid a £500 reservation deposit?
*
Please Select
Yes
No
If £500 reservation deposit received, this amount will be deducted from their first invoice
Third Party Contributors
Please complete this section if there are any third party contributions
Is there a third party contributing towards their care?
*
Please Select
Yes
No
Name of third party contributor
First Name
Last Name
Weekly contribution
Please detail in £000.00 format
Any other comments the finance team should be made aware of?
Name of manager completing this form
*
First Name
Last Name
Submit
Should be Empty: