Book a Room — Midtown Rest Haven

Room Rates

Starting at a subsidized rate.

including all Midtown Rest Haven services.

Proof of income

Social Security Award Letter
Pension Verification
Direct Deposit Statement
Other forms of verified income (Ex. Social Services commitment to pay agreement letter, self pay.)

Applicant Assessment / Profile Background History

Medical / Mental diagnosis (All applicants must be able to shower, clothe, and feed self without assistance) *shower chairs available
Medical Certification
COVID-19 Vaccination Record

Adult Partial Care Program Agreement

Please fill out application form in full.

Resident Application

Sender's / Agency Name

Who's submitting this application?

Sender's / Agency Phone Number

Sender's / Agency Email

Date of Application

Today's Date

Applicant's Name

First Name

Last Name

Date of Birth

Sex

Applicant's Current Address

Social Security Number

Marital Status

Mental / Medical Diagnosis

Medicaid

Name and Policy Number

Medicare

Name and Policy Number

Income

Income Amount

Allergies

Is applicant allergic to anything?

Emergency Contact

Name Relationship Address Phone Number