PRELIMINARY APPLICATION FOR EDEN SUPPORTIVE LIVING
How did you hear about us? Radio TV Newspaper Friend Other	Other:
Contact Information
Name:	Home Phone:	Cell Phone:
Address:	Apartment #:
City:	State:	ZIP:
Date of Birth:	Age:	Social Security Number:
Your Email:	OK to call? YES NO
GENERAL INFORMATION:
What is your yearly income?
Please indicate sources and amounts of income or medical reimbursement:
Employer:	Phone:
Position:	Monthly Salary:
Social Security NONE SSI SSDI SSA	Monthly Amount:
Public Aid NONE Link Medicaid	Monthly Amount:
Private Insurance:	Amount:
Pension Provider:	Monthly Amount:
Other:	Amount:
Please list the total cash value of ALL assets in your name
List of Assets:
Total Amount of Assets: (To qualify for Medicaid assistance your non-medical assets may not exceed $2000)
Marital Status: Single Married Widowed
Have you ever been evicted from an apartment? NO YES	If so, When?
Where do you currently live? Nursing Home Apartment Assisted living facility Private home Other	Other:
If you do not live in a care facility, do you currently work with a caregiver?: NO YES
Please Explain:
Please indicate below the amount of assistance you will need with the following tasks:
Toileting: Never Rarely Sometimes Always	Bathing/Showering: Never Rarely Sometimes Always	Grooming: Never Rarely Sometimes Always
Dressing: Never Rarely Sometimes Always	Medication Reminders: Never Rarely Sometimes Always	Eating: Never Rarely Sometimes Always
Laundry: Never Rarely Sometimes Always	Transferring/Walking: Never Rarely Sometimes Always	Incontinence: Never Rarely Sometimes Always
If incontinent, are you able to manage it by yourself?: NO YES
Frequency of Doctor Visits (per month):	(per year):
Current Health Status/Diagnosis/Ailment :
	Preliminary:
	Secondary:
	Tertiary:
Do you have a friend, who would qualify, whom would you like to have as a roomate?
Name:	Phone:
**Income inludes but is not limited to: Social Security, pension, stocks, bonds, interest, annuity, dividends, IRA, rental or other income. The applicant will be required to provide proof of all income sources before being approved.
I confirm that all of the statements made herein are true and complete to the best of my knowledge.