Referral for Charity

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Referral for Charity

Want to become an ambassador and make Referrals for Charity?  Join and make a referral by submitting this application.

 
Your First and Last Name *
Company *
E-mail *
Phone Number *
Anticipated Need for Housing or Discharge Date *
What type of senior housing do you feel would be best for this person? *
Location Desired by City, State, or Zip Code *
Nick Name or Reference Name (this information is for internal use only. In the event we need to contact you for more information, we will use this name you provide.) *
Age for person being Referred *
Gender *
Method of Payment *
Private Information
The information you provide for your monthly budget range is confidential and serves only so we can make proper recommendations that fit your financial profile.
If Private Pay Method: What is the monthly budget for housing and services? *
If Medicaid: What is the daily rate? *
Medical Needs/Services Required *
Specialty Care Certifications or Training Preferred *
Exhibiting Behaviors in: *
Transfer Requirements *
Ambulation Ability *
Additional Needs *
Do you have additional or other information you want to provide that will help with finding the best senior living option for your referral? *
As our ambassador, you agree to make honest referrals and to be available as needed. Once your referral moves into a community member of Senior Living Link, you will provide information for your favorite charity and agree to celebrate! You are indicating *