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Inquiry form

  1. sign

  2. Inquiry form for placement at Portage Manor (Form 2a)

  3. Financial Information

    Please check YES or NO to the following questions

  4. SSD*

  5. Medicare *

  6. SSI*

  7. Medicaid*

  8. VA*

  9. Vechicle*

  10. Home*

  11. Property*

  12. Burial Insurance*

  13. Health Insurance*

  14. Life Insurance*

  15. Checking Account*

  16. Savings Account*

  17. Medical Information

    Please check YES or NO to the following questions

  18. 1. Is there any history or evidence that the individual exhibits behavior that might present a danger to other residents, staff, and/or themselves?*

  19. 2. Does the individual have a documented diagnosis of intellectual disability, developmental delay, and/or other related conditions? *

  20. 3. Do they require assistance to ambulate? *

  21. 4. Do they dress themselves independently? *

  22. 5. Do they feed themselves independently and are able to chew and swallow without difficulty?*

  23. 6. Do they bathe themselves independently? *

  24. 7. Are they alert and oriented? *

  25. 8. Are they forgetful? *

  26. 9. Do they wander? *

  27. 10. Are they continent of bladder and bowel?*

  28. 11. Do they have special diet needs?*

  29. Internal Staff Only

  30. Leave This Blank:

  31. This field is not part of the form submission.