Assisted Living Application Form

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Phone: (540) 932‑3050
Email: info@sdretire.com
Address: 144 Patton Farm Road
Stuarts Draft, VA 24477

Schedule A Tour

Address: 94 Mountain Vista Drive , Stuarts Draft, VA 24477

Email: info@sdretire.com

Phone: (540) 932‑3050

Home
Pricing
- Assisted Living
- Independent Living
Contact Us
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About Us
- About Us
- Meet the Team
- FAQs
- Careers

Schedule a Tour

Contact Us

First Name:

Last Name

Middle Name

Maiden Name

Phone Number

Email

Date of Birth

Weight

Height

Country

Marital Status

Spouse Name

Number of Children

Permanent Home Address

City

U.S. State

Zip Code

Present Address (if different from above, i.e. institution, living with someone else, etc.)

Name(s) of Children and/or other pertinent relatives

Name of Contact Person

Phone Number

Address

Relation of involvement of contact person with applicant

Other person(s) to be contacted if above person cannot be reached:

Name of person responsible for applicant's financial affairs

Does applicant have:

Private Insurance

Medicare

Medicaid

Other

Explain, very briefly, applicant's potential to finance the monthly charges of this “Home”

Name of Pastor

Name of Church

Church Address

List any pertinent religious values, which should receive “special, dignified” attention if living in this institution (diets, rituals, etc.)

Occupation

List any other special group activities (please indicate past or present involvement):

Hobbies (in addition to the above):

Any other comments on social likes and dislikes:

List any relative(s), acquaintance(s) or friend(s), applicant may have in our institution:

Applicant's Doctor Name

Doctor's Address

Doctor's Phone Number

List any past or present illness known:

List any current treatments [NOTE: If applicant is presently residing in a short term care facility (hospital, extended care, etc.) please indicate name of facility, reason(s) for being there, and expected date of discharge]:

Speech:

Hearing

Sight

Explanation

Does applicant take care of own business?

Yes

No

Doe applicant drive their own car?

Yes

No

Does applicant ride in cars with others?

Yes

No

Does applicant visit, shop, etc., away from home with assistance

Yes

No

Does applicant cook their own meals?

Yes

No

Does applicant do their own laundry?

Does applicant help with minor household duties?

Yes

No

Does applicant bathe themself?

Yes

No

Does applicant dress themself?

Yes

No

Does applicant walk with assistance? (other person, care walker)

Yes

No

Does applicant need a wheelchair?

Yes

No

Does applicant have ability for visitation?

Yes

No

Have complication with self actualization (depression, withdrawal, etc.)

Yes

No

Summarize briefly the purpose of making application for admission and possible plans for present action or control until your (applicant’s) name is called.

Thank you for contacting us.
We will get back to you as soon as possible.

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Stuarts Draft Retirement Community is a family-owned assisted and independent living community rooted in faith, trust, and comfort.

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Home
Pricing
- Assisted Living
- Independent Living
Contact Us
Things to Do
About Us
- About Us
- Meet the Team
- FAQs
- Careers

Contact Information

Phone: (540) 932‑3050

Email: info@sdretire.com

Address: 94 Mountain Vista Drive, Stuarts Draft, VA 24477

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All Rights Reserved | Stuarts Draft Retirement Community.

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