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Robbie Caron
Kathy Kestler
Monica Pascual
Chris Skillicorn
Rejan Ferro
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Home
Services
Our Story
Meet our Team
Robbie Caron
Kathy Kestler
Monica Pascual
Chris Skillicorn
Rejan Ferro
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
Abbey Delray North
Allegro - Boynton Beach
Amy Decker - Senior Helpers/Senior Strategies
Arbor Oaks at Greenacres
Arden Courts of Delray
Atrium at Boca Raton
Avante
Banyan Place at Boca Raton
Banyan Place Lantana
Beach Breeze Rehab
Becky Dieter - Compassion Home Care
Boca Circle Rehah Center
Boca Del Mar Nursing
Boca Raton Rehab Center
Boca Raton Senior Rehabilitation
Boulevard Rehabilitation Center
Brighton Garden ALF
Brookdale Palm Beach Gardens
Cascades
Colonial Assisted Living at Palm Beach
Courtyard Gardens of Jupiter
Cresthaven Senior Living
Darcy Hall
Edgewater at Boca Pointe
Encore at Boca Raton
Faith Home Care
Five Stars Premier Residence Boca Raton
Florida Senior Care Solutions
Florida Sunshine Senior Placement
Fountainview
Grand Villa at Boynton Beach
Grand Villa of Delray Beach East
Grand Villa Senior Living Delray Beach
Google
Harbor's Edge at Delray Beach
Harborchase Coral Springs
Harborchase Wellington
Heartland Boynton Beach
Heartland Palm Beach Gardens
Isles of Boynton
Isles of Boynton Nursing and Rehab Center
JFK Hospital
Jodi Glacer - Senior Care Authority
John Knox Village
Jupiter Rehab
Label
Lakeside Health Center
Mama Llama
Mariposa
Menorah House Nursing Care
Meridian at Boca Raton
Next Door
Morselife Memory Care Residency
Oasis at Boynton Beach
Oasis at Margate
Online
ProMedica Skilled Nursing
Prosper Health & Rehabilitation Center
RCT Office
Sonata Boca Raton
Sonata Boynton Beach
Sonata Delray
Stratford Court of Boca Pointe
Terraces of Delray
The Arbor at Delray
The Carlisle Palm Beach
The Club at Boynton Beach
The Club at Wellington
The Elite Manor
The Heritage Delray
The Horizon Club
The Legacy at Boca Raton Rehabilitation and Nursing Center
The Luxe at Jupiter Healthcare
The Luxe at Wellington
The Palace at Weston Senior Living
The Pearl, Volante
Trustbridge
Ventura
VI at Lake Side
West Delray Nursing
Wilton Manors Health
Yamato Nursing and Rehab
Others
Other organization
Caller Name
(Required)
Client Name
Age
Caller Phone
(Required)
Facility Location/Date Admitted
Caller Email
Facility Address
Caller Address
Home Address
Other Contact
Client Phone
Caller Relationship
Email Address
Dx:
Mcr#
Disenroll
Yes
No
MCD Approved
Is there a POA in place?
Yes
No
Needed
Marital Status
Married
Widowed
Single
Divorced
Spouse Name
Mcr#
Spouse's Age
MCR Adv. plan
Spouse Income
Spouse Name
Spouse's Age
MCR Adv. plan
Veteran or Spouse of Veteran?
Yes
No
Needed
Disenroll
Yes
No
Income
Income Limit is $2,901 for 2025.
Social Security
Pension
VA
IRA RMD Monthly Distribution
Long-Term Care Policy
Other
Projected Monthly Gross Income
If Over Income Limit then QIT required
Yes
No
QIT Needed
Spouses can sign QIT if no POA
Real Estate Property
Yes
No
Car
Yes
No
Can have 2 cars if over 7 years old
Real Estate Property
Lawyer working with
John Williams
Alan Reinfeld
Other
Lawyer Consultation Needed for
POA
QIT
PSA
DEED
Spousal Diversion
Spousal Refusal
Pooled Trust
Lawyer working with Other
Attorney Price Note
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.
M&M Price Quote $
Notes
ADRC Referral
Palm Beach Country
Broward
Other
ADRC Referral Other
By
Monica Pascual
Kathy Kestler
Rejan Ferro
Lost
Unable to afford it
Follow-up
