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604 20th AVE SE Puyallup, WA 98372
Talk To Us:
(253) 225-0613
(253) 268-0497
(602) 315-0683
BOOK A VISIT
Email: adventlivingfh@gmail.com
604 20th AVE SE Puyallup, WA 98372
Talk To Us: (253) 225-0613 | (253) 268-0497
Email: adventlivingfh@gmail.com
Home
About
Services
Amenities
Gallery
Locations
Resources
Intake
Contacts
BOOK A VISIT
.
RESIDENT INTAKE FORM
Let’s get to know your care needs…
First Name
*
Last Name
*
Email Address
*
Phone Number
How did you find out about us?
*
Google
Facebook
Placement Agency
Friends and/ or Family
Other
Other
What is your relation to the resident?
*
Resident's Name
*
Age
*
Gender
Gender
Male
Female
Prefer not to say
Relevant medical and surgical history (with dates/year, if known)
*
Height (Approx)
*
Weight (Approx)
*
Reason for moving to an adult family home
*
Do you already have an "RN Assessment for AFH"?
*
Yes
No
Eating
*
Independent
Needing Assistance
Dependent
Personal Hygiene
*
Independent
Needing Assitance
Dependent
Bathing
*
Independent
Needing Assitance
Dependent
Toileting
*
Independent
Needing Assitance
Dependent
Mobility
*
Independent
Needing Assitance
Dependent
Transfers
*
Independent
Needing Assitance
Dependent
Medication Assistance
*
Yes
No
Other
Memory Issues
*
Yes
No
Other
Other
Other
Behavior
*
Skin Condition
*
Other information you want us to know
*
Current living situation
*
Own Home
Relative's Home
Hospital
Adult Family Home
Senior Living
Other
Other
Target move in date
*
Would you like a summary of disclosures of our rates and services, including itemized services?
Yes
No
Do you have any questions for us?
SUBMIT
