Prospective Elder Form This form is designed to insure that the prospective Elder meets our primary age and income requirements. The information is used solely for the purpose of connecting you with a St Luke's Home representative who will assist you. Are you interested in assisted living as a * Individual Couple Family member / Friend Professional Is this information for an individual or couple? * Individual Couple Your Name ( first & last) * Your Gender Male Female Individual's Name ( first & last) * Individual's Gender Male Female Partner's Name ( first & last) * Partner's Gender Male Female Phone Number * Email We use this to send you important application documents. If you do not have access to email, leave blank. Address * Address Line 2 City * State * AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Postal Code * Are you 55 years or older? * Yes No Are you and your partner 55 years or older? * Yes No Are they 55 years or older? * Yes No Is your annual income below $28,860? * Yes No What is your monthly income? * Is their annual income below $28,860? * Yes No What is their monthly income? * Is your combined annual income as a couple below $32,940? * Yes No What is your combined monthly income as a couple? * Is their total combined annual income as a couple below $32,940? * Yes No When do you and/or your loved one plan to move into assisted living? * Within 1 month 1-3 months 3-6 months 6+ months I don't know What is their combined monthly income as a couple? * How did you hear about us? * Family or Friends Professional (Doctor, Case Manager, Social Worker etc.) Internet Other: Please tell us how you heard about us. reCAPTCHA If you are human, leave this field blank.
