Admissions Application

Embarking on a new chapter is a significant and personal journey. We are honored that you are considering Saint Simeon’s as your new home and are here to support you every step of the way.

Please complete the application below with as much detail as possible. This confidential information helps us understand your unique needs and how we can best serve you. For a complete overview of our process, please see our Admissions Information page.

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Name

This field is for validation purposes and should be left unchanged.

Area of Interest

Assisted Living

Assisted Living Memory Care

Long-term Care

Long-term Care Memory Care

Unknown

Select one or more area of your interest in our community.

Personal Information

Applicant's Name

First Middle Last

Social Security #

Marital Status

Spouse's Name

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Date of Birth

Age

Sex

Previous Occupation

Employer

Have any family members resided at Saint Simeon's?

Yes

No

Name of Family Member

Relationship

Medical Information

Attending Physician (PCP)

Phone

Address

Street Address City State / Province / Region ZIP / Postal Code

Hospital Preference

Representative/Emergency Contact

*Documentation is Required. Please check one:

*Durable Power of Attorney

*Financial Power of Attorney ONLY

*Health Care Power of Attorney ONLY

*Court Appointed Guardian

Other

Name

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code

Business Phone

Home Phone

Cell Phone

Email

Financial Information

Finances are administered by:

Resident

Representative

Name of Representative

First Last

Relationship

Phone

Email

Address

Street Address City State / Province / Region ZIP / Postal Code

Assets & Monthly Income:

Checking Account Balance

Pension

Savings Account Balance

Social Security

CD/IRA/TDA/TSA

Trust Income

Stocks & Bonds

Dividends

Real Estate

VA Benefits

Personal Property

Spousal Benefits

Other Assets

Other Income

Total Assets

Total Income

Long-Term Insurance

Do you have Long-Term Care insurance?

Yes

No

Insurance Company

Policy Coverage

Who Referred You to Saint Simeon's?

Name

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code

Business Phone

Home Phone

Cell Phone

Please indicate how you heard about Saint Simeon's. (Check all that apply.)

Physician

Website

Friend

Alzheimer’s Association

Hospital Personnel

Life Senior Services

Case Manager

Magazine Ad

Church

Radio Ad

Relative of a Resident

Other

If Other, How did you hear about Saint Simeon's?

I certify that this application is made of my own free will and volition and that the information is correct to the best of my knowledge. I authorize and request that my attending physician, surgeon, or other persons having direct, professional knowledge of my physical or mental health, past or present, provide to the staff of Saint Simeon’s Episcopal Home any and all information relative to this application.

Signature

Date

What to Expect Next

• Our admissions team will carefully and confidentially review your application.
• We will contact you or your representative within two business days to confirm we’ve received your information.
• We will then work with you to schedule a personal consultation to discuss the next steps.

We’re Here to Help

Completing an application can bring up questions. If you need any assistance or would prefer to speak with someone directly, please don’t hesitate to get in touch. You can find our contact information on the Contact Us page. We look forward to connecting with you.