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Kathy Kestler
Monica Pascual
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Home
Services
Our Story
Meet our Team
Robbie Caron
Kathy Kestler
Monica Pascual
Medicaid Benefits
Living Options
Resources
Contact
Blog
Newsletter
Intake Form
Consult Date
(Required)
MM slash DD slash YYYY
Time
(Required)
Hours
:
Minutes
AM
PM
AM/PM
Referred By
Organization
Jodi Glacer - Senior Care Authority
Becky Dieter - Compassion Home Care
Florida Sunshine Senior Placement
Florida Senior Care Solutions
Faith Home Care
Abbey Delray North
Abbey Delray South
Isles of Boynton Nursing and Rehab Center
The Luxe at Jupiter Healthcare
Grand Villa Senior Living Delray Beach
Amy Decker - Senior Helpers/Senior Strategies
Courtyard Gardens of Jupiter
Jupiter Rehab
Heartland Boynton Beach
Isles of Boynton
Banyan Place Lantana
West Delray Nursing
Avante
Yamato Nursing and Rehab
Sonata Delray
The Legacy at Boca Raton Rehabilitation and Nursing Center
Harborchase Wellington
Banyan Place at Boca Raton
Menorah House Nursing Care
Darcy Hall
Terraces of Delray
Heartland Palm Beach Gardens
JFK Hospital
Grand Villa of Delray Beach East
Stratford Court of Boca Pointe
Lakeside Health Center
Harborchase Coral Springs
Brighton Garden ALF
Sonata Boca Raton
Ventura
Boulevard Rehabilitation Center
Heartland Boynton Beach
Prosper Health & Rehabilitation Center
The Heritage Delray
Boca Raton Senior Rehabilitation
The Elite Manor
Edgewater at Boca Pointe
The Palace at Weston Senior Living
Atrium at Boca Raton
Five Stars Premier Residence Boca Raton
Meridian at Boca Raton
The Club at Wellington
The Club at Boynton Beach
Grand Villa at Boynton Beach
Allegro - Boynton Beach
Oasis at Boynton Beach
Sonata Boynton Beach
The Arbor at Delray
The Horizon Club
Arden Courts of Delray
Arbor Oaks at Greenacres
The Carlisle Palm Beach
Mariposa
VI at Lake Side
Oasis at Margate
Mama Llama
Colonial Assisted Living at Palm Beach
Fountainview
Cresthaven Senior Living
Morselife Memory Care Residency
Boca Circle Rehah Center
Boca Del Mar Nursing
Boca Raton Rehab Center
Encore at Boca Raton
ProMedica Skilled Nursing
Harbor's Edge at Delray Beach
John Knox Village
Beach Breeze Rehab
Wilton Manors Health
The Luxe at Wellington
The Pearl, Volante
Brookdale Palm Beach Gardens
Trustbridge
RCT Office
Caller Name
(Required)
Caller Phone
(Required)
Caller Email
Caller Relationship
Caller Address
Other Contact
Client Name
Age
Facility Location/Date Admitted
Facility Address
Home Address
Client Phone
Email Address
Dx:
Mcr#
Disenroll
Yes
No
MCD Approved
Is there a POA in place?
Yes
No
Needed
Marital Status
Married
Widowed
Single
Divorced
Spouce Name
Mcr#
Spouse's Age
MCR Adv. plan
Disenroll
Yes
No
Veteran or Spouse of Veteran?
Yes
No
Needed
Social Security Income: Income Limit is $2,901.00 for 2025
Pension
VA
IRA RMD Monthly Distribution
Long-Term Care Policy
Other
Projected Monthly Gross Income
If Over Income Limit then QIT required
Yes
No
OIT Needed
Spouses can sign QIT if no POA
Real Estate Property
Car
Yes
No
Can have 2 cars if over 7 years old
Assets
List all investments/retirement accounts
Bank Accounts Check
Bank Accounts Check
Bank Account Savings
IRA
C.D./Stocks/Bonds/Annuities
Life Insurance
Spouse Life Insurance
Burial Account
Projected Gross Total Assets = $
Single person allowed House/Car and $2,000 assets. Community Spouse allowed House/Car and $154,000.
Lawyer working with
John Williams
Alan Reinfeld
Other
Lawyer working with Other
Lawyer Consultation Needed for
POA
QIT
PSA
DEED
Spousal Diversion
Spousal Refusal
Pooled Trust
Attorney Price Note
M&M Price Quote $
Notes
ADRC Referral
Palm Beach Country
Broward
Other
ADRC Referral Other
By
Monica Pascual
Kathy Kestler
Rejan Ferro
