Crutchfield Family Living
Senior Living Waitlist Intake Form
Resident Information
Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact
Full Name
*
First Name
Last Name
Relationship
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Medical / Care Information
Do you require assistance with daily activities
*
Yes
No
If yes, please explain
*
Primary Care Physician
*
Physician Phone
*
Do you use mobility aids?
*
None
Walker
Cane
Wheelchair
Other
Known Allergies
*
Current Medications
*
Housing Preferences
Preferred Room Type
*
Shared Private Bedroom
Fully Private Bedroom (when available)
Move-in Timeline
*
Immediate
Within 30 days
1–3 months
6+ months
Monthly Budget Range
*
$800–$900
$900–$1,000
$1,000+
Lifestyle & Services
Transportation Needs
*
Doctor Appointments
Pharmacy/Grocery Trips
Other
Financial Information
Payment Source
*
Private Pay
Family Assistance
Other
Additional Notes
Signature
Resident / Responsible Party
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: