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7235 North Loop Drive El Paso TX, 79915 (915) 775-1965
RESIDENT INTEREST FORM
*Pricing is determined after full assessment of interested individuals*
*
Indicates required field
Contact Name
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First
Last
Phone Number
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Email
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Method of payment. Only 3 methods accepted for our home.
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Private Pay
Amerigroup Star+plus waiver
Molina Star+plus waiver
Current location of individual:
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Personal / Family Home
Hospital
Rehab / Nursing Home
Assisted Living / Foster Home
Other
Services Needed
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Feeding assistance by provider
Incontinence care
Bathing Assistance
Transfer care: Wheel chair to Bed. Bed to chair
General Supervision
OTHER: Please explain in comment box
Tours and interviews are Monday - Friday 8 a.m. - 11:30 a.m. Will you be able to meet those schedules?
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Yes
No
Other: Please explain in comment box
Estimated move-in date
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Comments. Questions.
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Submit
Tours - Assessment - Interviews
By Appointment Only
Monday - Friday
8 a.m. - 11:30 a.m.
TELEPHONE NUMBER
(915) 775-1965
PHYSICAL ADDRESS
7235 N. Loop Dr.
El Paso, TX 79915
PARKING