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Elder Day Stay is currently operating off of a waitlist for services. To be added to the general waitlist, please complete the form below or call 850-222-4208.
A limited number of priority enrollment spots are available to clients who are appropriate for the program and can meet the monthly fee of $1500.
General Information
Client Name
*
Client's Date of Birth
*
(mm/dd/yyyy)
Name of Caregiver
Contact Number
Email
Verify Email
Client Information
Service Interest
*
Priority Enrollment ($1,500/month)
Waitlist (subsidized, insurance, or state-funded services)
Unsure
Is this client able to stand up without being lifted?
*
Yes
No
Unsure
Is this client enrolled in a program that would cover Adult Day Care? (LTC Medicaid, ADI, CCE, HCE, LSP)
*
Yes
No
If yes, please list the program(s), and if applicable, the name of the case manager.
Provide additional information about this client’s needs while attending.