Please fill out the form below to enquire about residency at Howard House Name* Email* Phone Number* Preferred Method of Contact* Email Phone Either Preferred Time of Day to be Contacted* Morning: 8am-11am Afternoon: 11am-3pm Evening: 3pm-7pm Questions about the Potential Howard House Resident Name of the Potential Resident* Potential Resident's gender identification male female What is the age of the potential resident?* When would the potential resident want to move in?* Is the potential resident diabetic?* Yes, Type I Yes, Type II No, he/she is not diabetic Does the potential resident need assistance from an ambulatory aide? (i.e. wheelchair, walker, cane, AFO)* Yes No 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?* Yes, either is fine No, female caretakers only No, male caretakers only 4 + 10 = ? Submit to Howard House
