Align Administration Questionnaire - YoloCare Websites

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Align Administration Questionnaire

Name of your Facility:

Type of Facility (check all that apply):

Skilled Nursing

Assisted Living

Memory Care

Independent Living

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Community Phone

Community Fax

How long has your facility been serving the community:

Emails

Email addresses for forms (may go to more than one email address) We highly recommend a universal email address (for example: info@facility.com or admissions@facility.com)

Email of best contact person for the Web Development:

Contact Us form:

Send a Greeting cards:

Schedule a Tour form:

Employment Application:

Awards

Do you have any current awards? (i.e.: CMS Overall Star Rating, Best in Care, US News & World Report, Newsweek, etc)

List all Awards

Services

Check services you offer (check all that apply):

Short-term Rehab

Long-term Care

Sub-Acute Care

24-hour Skilled Nursing

Restorative Nursing

Stroke Recovery

VAD Care

Pain Management

Dietary Program

Outpatient Therapy

Wound Care

Diabetes Care

Behavioral Health

Alzheimer’s and Dementia Care

Respiratory Therapy

Physical Therapy

Occupational Therapy

Speech Therapy

Pulmonary Program

Respite Care

Hospice Services

Social Services

Beauty Salon Services

Other services, not listed above that you want to highlight:

Assisted Living Services

Assisted Living Services (if applicable, check all that apply):

Family Dining

Restaurant Style Dining

Meal Plans

Housekeeping

Laundry

Safety/Security

Assistance with Daily Living

Wellness programs

Transportation services

Personal pets allowed

Please explain any restrictions on Pets:

Other services, not listed above that you want to highlight:

Independent Living Services

Independent Living Services (if applicable, check all that apply):

Housekeeping

Laundry services

Linen service

Maintenance/handyman services

Emergency Call system

Security patrols

Concierge services

Transportation services

Restaurant style dining

Chef prepared meals

Fitness classes

Walking groups

On-site fitness gym

Wellness seminars

Community

Do you have floor plans for the Community?

Does your facility/campus have a tagline? (i.e.”Compassionately Caring for You”):

What types of activities do you offer? (check all that apply)

Arts & Crafts

Music/sing alongs

Group Games

Puzzles

Seasonal celebrations

Fitness/mobility activities

Religious services

Outings/Community events

Pet Therapy

Any other types of activities not listed?

Frequently Asked Questions:

We will cover some of the basic FAQs, but here are some answers we would need for your specific facility:

What insurances do you accept (please include medicare waivers, etc)?

Do you offer video chats for virtual tours?

What is your visitor policy?

Are pets allowed for visiting?

Do you have a sample activity calendar (without the month and year) we can post on the website?

Any other information you would like us to have?

*Once you submit this form, a confirmation page will pop up with a link to Dropbox to submit any images, sample calendar, floor plans, etc. that you may have.

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