FEES, NEEDS, & CONTRACTS
Entrance Fee: (if applicable) $ _____$ _____ $ _____
Deposit: (if applicable) $ _____$ _____ $ _____
Monthly Rate: private rm/apt. $ _____$ _____ $ _____
Monthly Rate: shared (pp) $ _____$ _____ $ _____
Does Monthly Rate Include: If No, the Extra Cost is:
3 meals and snacks per day? $ _____$ _____ $ _____
Weekly housekeeping? $ _____$ _____ $ _____
Making bed daily? $ _____$ _____ $ _____
Washing linens? (sheets & towels) $ _____$ _____ $ _____
Personal laundry? $ _____$ _____ $ _____
Parking space for my car? $ _____$ _____ $ _____
Transportation to medical appts? $ _____$ _____ $ _____
Transportation to shopping? $ _____$ _____ $ _____
Telephone service? $ _____$ _____ $ _____
Cable TV? $ _____$ _____ $ _____
Help with medications? $ _____$ _____ $ _____
Help with bathing? $ _____$ _____ $ _____
Help with dressing/grooming? $ _____$ _____ $ _____
Help with incontinence? $ _____$ _____ $ _____
Help with eating? $ _____$ _____ $ _____
Help for dementia? $ _____$ _____ $ _____
Misc.: $ _____$ _____ $ _____
Misc.: $ _____$ _____ $ _____
Total Monthly Cost of Extras: $ _____$ _____ $ _____
Total Monthly Cost: $ _____$ _____ $ _____