Future Resident Pre-Admission Application (Veteran Residential Care)
All information is confidential and used to determine care eligibility and financial qualification.
Section 1: Veteran Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Branch of Service
Please Select
Army
Navy
Air Force
Marines
Coast Guard
Space Force
Other
Section 2: Primary Contact / Responsible Party
Full Name
*
First Name
Last Name
Relationship to Veteran
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Section 3: Current Living Situation
Current Living Situation
*
Private Home
Living With Family
Hospital
Rehabilitation Facility
Assisted Living
Skilled Nursing
Other
Section 4: Level of Assistance Needed
Level of Assistance Needed (Select all that apply)
Bathing
Dressing
Medication Management
Mobility Assistance
Memory Support
Continence Care
Minimal Assistance Needed
Section 5: Medical Overview
Please briefly list any major diagnoses, mobility limitations, or health concerns.
Section 6: Monthly Income & Financial Qualification
Social Security Monthly Amount (USD)
*
VA Disability Monthly Amount (USD)
*
Pension Monthly Amount (USD)
*
Retirement / Other Monthly Income (USD)
*
Total Estimated Monthly Income
Section 7: VA Benefit Status
VA Benefit Status
Currently Receiving Aid & Attendance
Approved for VA Pension
Application in Process
Not Receiving VA Benefits
Unsure
Section 8: Financial Responsibility
Financial Responsibility
Veteran
Family Member
Power of Attorney
Conservator
Other
Section 9: Desired Move-In Timeline
Desired Move-In Timeline
Immediate (Within 2 Weeks)
Within 30 Days
Within 60 Days
Exploring Options
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