Enquire About Residency at Howard House - San Diego Brain Injury Foundation

Name*

Email*

Phone Number*

Preferred Method of Contact*

Preferred Time of Day to be Contacted*

Name of the Potential Resident*

Potential Resident's gender identification

What is the age of the potential resident?*

When would the potential resident want to move in?*

Is the potential resident diabetic?*

Does the potential resident need assistance from an ambulatory aide? (i.e. wheelchair, walker, cane, AFO)*

What is the level of care needed for the potential resident? (i.e. help with using the restroom, taking a shower, feeding, etc.)*

What are you and the potential resident looking for in an assisted living home environment?*

Are you and the potential resident comfortable working with male and female caregivers?*

2 + 5 = ?