Website FormHere the provider can enter all information needed to build and maintain their customized website.Please enable JavaScript in your browser to complete this form.Personal/Business Information - Step 1 of 2Home Name *Enter the name of your home.Provider Name *FirstLastEnter First and Last name.Provider Bio *Give a short bio about yourself. (ie. what you have achieved, where you are originally from, your interests etc.)Provider Profile Picture * Click or drag a file to this area to upload. Add a Portrait photo of the Provider for the front page on the top.Background Image * Click or drag a file to this area to upload. Add a Background photo for the top section of the website.Statement of Home (what makes us special) *Describe the feel of the home and its surrounding area. (No stats)Private Bedrooms *- select number -12345678910Select how many bedrooms are available in your home.Bathrooms *- select number -12345+Select how many bathrooms are available in your home.Residents *- select number -123456+Select how many residents are currently in your home.Caregivers *- select number -123456+Select how many Caregivers are currently in your home.Finished Sq. Ft. Selected Value: 1000Select the square feet of your home.Year Opened Selected Value: 1940Select the year your home was built.Walking Paths *YesNoDoes your home have any walk paths?Outdoor Patio *YesNoDoes your home have a patio?Home Accreditation/Certification *Better Business BureauAdult Family Home CouncilCPRAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAdd the address for your home.Phone Number *Enter the main phone number for your home.Email *EmailConfirm EmailEnter contact email for your home.Do you have a Social Media? *YesNoDo you have a personal Social Media you would like to use for your website?If yes, is this a personal or business Social Media account? *PersonalBusinessAre we able to gain access to this account to create a business account? *YesNoWe would like to create a business account for you.Select the Social Media's you would like to include on your website:FacebookLinkedInYouTubeOtherFacebook URL *Enter the Facebook URL for your home.LinkedIn URL *Enter the LinkedIn URL for your home.YouTube URL *Enter the YouTube URL for your Channel.Other URL *Enter the URL.NextCare Services *Age-related conditionsAlzheimer’sArthritisBed-boundCongestive heart failureDementiaDevelopmentally DisabledDiabetesStroke PatientsTwo person transfersNeurological problemsParkinson’sRegistered nurse delegationRespite careIncontinence carecatheter careMental Health and DepressionOtherSelect the care services you provide in your home.Care Services - Description *Example: Our homes are operated and supervised by a team of nurses, health care directors, and resident managers who ensure coordination of care, adequate staffing, finance management, compliance, marketing, and collaboration with outside health organizations and providers.Other Care Services *Type in any other care services.Levels of Care *Example: Activities of Daily Living (ADL’s) consists of personal care tasks such as toileting, bathing, dressing, feeding, and cognitive ability to recognize when help is needed.Care Level 1:Ambulatory – Can walk without assistanceAble to complete their ADL’s on their ownMedication management does not need supervisionCompanionship by engaging in fun activities as an individual or in a groupSelect the care included in care level 1.Care Level 2:Ambulatory with guidance or help from aid, cane, walkerAble to complete their ADL’s with the assistance of 1 person, guidance, cueing, and reminders as neededMedication management with supervisionIndividual or group activities with assistanceSelect the care included in care level 2.Care Level 3:Ambulatory with a wheelchair; 1-2 person transfer assistanceModerate assistance with ADL’s and supervision at all timesMedication management full supervisionCare coordination with the auxiliary healthcare teamSelect the care included in care level 3.Care Level 4:Impaired or non-ambulatory; 2 person assistance with transferring or bed-boundTotal assistance with ADL’s and all personal care, catheter careMedication management full supervision and administrationCare coordination for the auxiliary healthcare teamHealth maintenance such as vitals, diabetes, anticoagulation therapy, injectable therapy, cancer care, hospiceFeeding TubeNephrostomy CareSelect the care included in care level 4. Quality of Life Activities *PuzzlesWord GamesCardsArts & Crafts SuppliesOtherSelect quality of life activities your home offers.Other Activities *Add any other Activities that will be in the home.Groups *Theme PartiesMocktail HourDay TripsConcerts (In Person or Virtual)BingoPaintingGardeningMovie NightGentle YogaChair Exercise HourOtherSelect the available groups your home offers.Other Groups *Add any other Groups that will be in the home.Photo Gallery of Home Click or drag files to this area to upload. You can upload up to 20 files. Upload desired photos for your home.Would you like a copy of this form? *YesNoSubmit