Holly Mapleton Application Form

Application Form
Section 1: Applicant / Primary Contact
Applicant Full Name*

First NameLast Name
E-mail
example@example.com
Phone Number*
Please enter a valid phone number.
Relationship to Resident*

SelfAdult ChildSpouse/PartnerOther
If ‘Other,’ please specify
Preferred Contact Method

CallTextEmail
Best Time to Reach You

MorningAfternoonEveningAnytime
Section 2: Prospective Resident Information
Prospective Resident*

First NameLast Name
Resident Age Range*

55-6465-7475-8485+Prefer not to say
Primary Language
Preferred Move-In Timing:*
Preferred Living Option*
Support Needs & Preferences (check all that apply)*

HousekeepingMeals/snacksErrands/scheduling helpPersonal care/Assistance with daily livingMedication remindersSocial connectionOther
Other (please specify)
Mobility (check all that apply)*

IndependentCane WalkerWheelchairNeeds transfer helpCan transfer IndependentlyNot sure/ needs assessment
Falls in the last 12 months?*

YesNoPrefer to discuss
Memory/cognition concerns?*

YesNoPrefer to discuss
Payment / Funding (check all that apply)*

Private PayLong-term care insuranceMedicaid/HCBS WaiverVA BenefitsLife InsurancePrefer to discuss
Any other concerns you would like to bring up with our team before we connect?
Section 3: Authorized Representative (if applicable)

Complete if someone may make decisions, sign paperwork, receive updates on the resident’s behalf.
Authorized Representative

YesNo
Representative Name

First NameLast Name
E-mail
example@example.com
Phone Number
Please enter a valid phone number.
Relationship to Resident
Type of Authority

Power of AttorneyHealthcare ProxyGuardianOther
Other (please specify)
By submitting this Application, I understand and agree that:

1. The information I provided is true, complete, and accurate to the best of my knowledge. I understand that incomplete or false information may result in the application being declined.

2. Submission of this Application does not guarantee placement or a room lease. A room is reserved only after a written lease is completed and signed by all required parties.

3. This is an application intended to help determine fit and next steps. Additional information may be requested, and a separate intake form may be required after acceptance/commitment and prior to move-in.

4. I understand Holly Mapleton is a pet-free home and pets are not permitted.

5. I authorize Holly Mapleton to contact me using the phone number and/or email I provided to follow up on this Application.

6. If I selected text as my preferred contact method, I consent to receive text messages related to this Application. Message/data rates may apply. I may opt out at any time.
Confirm*

I Agree
Name*

First NameLast Name
Date*
Should be Empty:

Application Form

Section 1: Applicant / Primary Contact

Section 2: Prospective Resident Information

Section 3: Authorized Representative (if applicable)