Making the right decision about senior living for you or your loved one can be overwhelming. Let us help you.

Assisted Living offers support with daily living in a safe home-like setting providing peace of mind to residents and their families. Residents of Christopher Heights™ maintain their independence through our care and wellness programs. Christopher Heights offers a variety of programs to meet your way of life while you receive quality care in a warm and supportive environment. Additional help is available when necessary.

PRELIMINARY APPLICATION FOR RESIDENCY

General Information
Medical Information
Financial Information
Housing Information
Final Verification

Create Account

Please enter your email and a secure password. This will allow you to come back to complete the application at any time:

Email Address

Password

Repeat Password

I. General information concerning prospective resident(s):

Which location are you interested in?

How did you learn about us?

Applicant’s Name

Age

Date of Birth

Current Gender Identity

Biological Sex

Social Security Number

Home Address

Telephone Number

Own Home

Rent

Occupation

Marital Status

Co-Applicant Information

Co-applicant's Name

Co-applicant's Age

Co-applicant's Date of Birth

Co-applicant's Social Security Number

Are you or your partner (living or deceased) a Veteran who was on active duty during a time of war?

Responsible Party Information:

Is applicant responsible for managing own finances?

If no, please list name of responsible party:

Name of Responsible Party

Address

Telephone Number - Business

Telephone Number - Home

E-mail Address

Cell

Power of Attorney Information:

Does applicant have a Power of Attorney (POA)?

POA Name

Address

Telephone Number - Business

Telephone Number - Home

E-mail Address

Cell

Guardian/conservator Information:

Does applicant have guardian/conservator?

Name

Address

Telephone Number - Business

Telephone Number - Home

Does applicant have a Health Care Proxy?

Has the HCP been invoked?

In case of emergency, whom should we notify?

Name

Relationship

Address

Telephone Number - Business

Telephone Number - Home

E-mail Address

Cell