Commonwealth House Assisted Living
Prospective Resident Application Form
This form can be completed by the applicant on behalf of the prospective resident, or by the prospective resident directly. Please answer all questions as accurately as possible. Thank you!
First let us collect some basic information...
Prospective Resident's Date of Birth
*
Now help us learn a little more about the resident...
What is the Prospective Resident's current living situation?
Here we learn more about paying for our service...
***Please note that our private rooms start
at an all-inclusive rate of $6000/mo.***
Does the resident have the ability to pay privately?*
If yes, where will the funds used to pay the monthly rate be coming from?
If no, has the resident applied and been approved to receive MEDICAID LTSS?
Thank you for your interest in Commonwealth House! We hope we can provide the warm and caring community for you or your loved one that you have always dreamed about. We will reach out soon to discuss next steps!
-Owners Mandi and Graham Willoughby
