Assisted Living Application for Admission

Date of Referral:

Facility Applying To:

Arbor Terrace - Gardiner, Maine Berwick Estates - South Berwick, Maine Biddeford Estates - Biddeford, Maine Pinewood Terrace - Farmington, Maine All of the Above

Resident's Name:

Resident's Gender:

Female Male

Resident's Date of Birth:

Resident's Address:

Marital Status:

Married Single Divorced Widowed

Present Living Location:

In Own Home Hospital Other

What service(s) are being requested?

Residential Care/Assisted Living

Respite/Short Stay

Payment Options:

Privately Funded/Self Pay

Long Term Care Insurance

MaineCare (Medicaid)

Does the Resident Have a:

Guardian

Healthcare Power of Attorney

Financial Power of Attorney

Conservator

Living Will

Does the Resident Manage His/Her Own Affairs?

Yes No

Tobacco Use:

Current Tobacco User Does Not Use Tobacco

Mobility:

Cane

Walker

Wheelchair

Able to Move Up/Down Stairs

No Assistive Equipment Needed

Contact Name:

Relationship to Resident:

Email:

Phone Number:

Address:

Preferred Method of Contact:

Email

Phone

Mail

Please share any additional information that we should be aware of:

How did you hear about New CommunitiesArbor TerraceBerwick EstatesBiddeford EstatesPinewood Terrace: