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Zip Code
Do you own the property? Yes
No
Whose name is on the deed?
Best day and time to contact you? (Please provide 3 options)
Property Information
Do you have a pool? (Need to take water safety class) Yes
No
Do you have a septic tank? Yes
No
Do you live in the house? Yes
No
What are your plans for moving
Do you have caregiving experience? What do you do for a living?
What have you done so far in the process?
Where do you feel stuck?
Who are the parties that will own the assisted living?
What are their names?
What are their email/s and phone number/s?
What's the percentage of the ownership for each owner?
Do you have an LLC yet? Yes
No
Do you have an NPI (National Provider Number) yet? Yes
No
Have you applied for Medicaid in the past? Any issues with Medicaid?
Any background issues for anyone who will be involved in the business? Must be able to pass a level two background.
Have you completed the core training or the 12 hour AFCH class? Yes
No
Who will be the administrator?
What is the budget for your facility licensing project?
Do you know you will need a fire alarm, fire sprinkler, generator, reserve gas & money reserve for the proof of ability to operate? Yes
No
What services are you looking for?
Have you received the zoning approval yet? Yes
No
Is there anything else you want to tell us?
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