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Placement Referral Help for Seniors

                                         

 

Adult Group Homes and Assisted Living Communities

 

 

Would you like to be part of our preferred Adult Group Homes or Assisted Living ? We invite you to inform us of your facility (s). Our procedure is simple. Fill out the form below and we will schedule a tour of your facility. We will perform an onsite inspection to assess the level of care you are performing as well as the cleanliness's and pleasantness of the surroundings for clients. We will also verify with the State of Nevada or California. your license status for our clients protection. We look forward to working with you and assisting you in placements. Our Staff will be contacting you in the future for a convenient time for touring.

We service all areas of Nevada and California so feel free to join our team no matter where you are. For those who are out of state we will be glad to work with you and place our out of state clients in your area.

  * Required Fields

 

 

 

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   New Adult Group Homes Only

 

   * Name of Facility   

   * Address            

   * City        *State       *Zip

   * Phone     Fax    *Email

   * Owners Name    Owners Cellular

   Owners Home#          * License Number

   Administrator     Marketing Director

   Accounts Payable Contact  

   Please answer all that applies to your facility.  Make a choice for drop down menus.

    Assisted Living (Large Facility over 10)      Adult Group Home 2-10 beds      Room and Board     HIC

   Mentally Disabled         Chronic Illness    # Beds   

   Independent Living      Retirement      

    2nd diagnosis not primary for :  Dementia           Alzheimer     

   Care for Hospice clients

   Separate Memory Care Unit             Gated             Alarms on doors

   Combative clients        Wanderers         Sundowner      Smokers allowed outside

   Diabetic          Insulin        Diabetic Diet       Oxygen  

   Incontinent         Catheters     Colostomy      Dialysis Client

   Bi Polar     Depression      Respites       Stand By Assist         Max Transfer

   Slider Board         Walker and Wheelchairs welcome?      Transport to appt 

   Do you have a PM staff that is awake? RN/LVNs on Staff

   Wounds:   1st    2nd          Activities     Pets allowed    Level of Care

   SNF attached to AL     More home?    Population  


   Please list the price of a semi-private first.

   Semi-Private  Price:   Kitchens     Partial Kit

   One Bdrm   Price:     Kitchens   Partial Kit

   2 Bdrm        Price:    Kitchens   Partial Kit

   Cottages        Price:    Kitchens   Partial Kit

    Do you have               All Privates?             Shared units?

   SSI clients        Non Refundable Deposits           Community Fee

    Comments or Amenities

    Directions

See our Membership Marketing Benefits

have access to discharge planners 24/7

 

Thank you for your time and we look forward to a good working relationship. For any questions regarding this form you may call the office at 702 839-4692

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