Provider's Name:

Partner or Resident Manager:

AFH License #:

Address:

Address 2:

City:

State:

Zip:

Area:

Phone:

Phone 2:

Cell Phone:

Pager:

800 number:

Fax:

Fax Need To Call First:

Alternate email:

Email:

Web Address:

Owner live on site:

Medical professional:

Licensed for # of residents:

Year home first licensed:

Sexes cared for:

Nurse delegation:

Provide care to:

Accept bedridden residents:

Emphasis on Alzheimer's & Dementia care:

Staffing - 24-hour awake staff:

Highest designation of Owner/Provider:

How often is owner in the home?:

How often is nurse in the home?:

Is a nurse on call 24/7:

Physician making house calls:

24-hour toileting:

Incontinence Management:

Transfer assistance available:

Diabetes - non-insulin:

Diabetes - requires insulin injections:

Accommodate special diets:

Hospice care available:

Accept Hospice upon Admission:

Intend to provide life-long care for residents:

Transport to doctor appointments:

Transportation for outings:

Provide care for those who wander:

Alarm system for those who wander:

Yard fenced:

Air Conditioning:

Floor Coverings / Community Spaces:

Floor Coverings / Resident Rooms:

Bathrooms:

Showers / Tubs:

Walk-in Showers:

Roll-in Showers:

Room with private bath:

Private rooms:

Semi-private rooms:

Home type:

Is home wheelchair accessible?:

Approximate square footage available for residents:

Is this a view home:

Are there stairs inside the home?:

Children in the home:

Smoking allowed?:

Pets in the home:

Home may allow someone to bring a pet:

Languages spoken (other than English):

Activities offered:

Comments:

Public Note:

Current price range (private room):

Certification For Alzheimer's:

Certification For Mental Health:

Certification For Development Disabilities:

Medicaid Accepted: