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Nick's House Application
Contact Information
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First Name
Last Name
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
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(mm/dd/yyyy)
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First Name
Last Name
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Monday through Friday between 9am and 3pm
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Monday through Friday 9am to 12pm
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(mm/dd/yyyy)
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Treating Physician Information
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Prefix
First Name
Last Name
Suffix
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
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By clicking this button, you authorize HEADstrong Foundation to contact your medical team to validate this application and you have made them aware of your application for a stay at Nick's House
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First Name
Last Name
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Other Guests Staying with Patient
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First Name
Last Name
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(mm/dd/yyyy)
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
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First Name
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Do you have more guests then just the caregiver staying with you?
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First Name
Last Name
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(mm/dd/yyyy)
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
Additional Information
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Nick's House is ADA handicapped accessible.
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Electronic Certification
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Residency applicants must meet all the following eligility
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By clicking below, you are providing consent for us to reach out to you for a background check. This must be completed prior to our approval for your stay at Nick's House.
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Nick’s House is not a healthcare facility and may not be used for the purpose of the administration of medical care or therapies, including, without limitation, palliative or hospice care. HF makes its residential facilities available for such persons from time to time, in the HF’s sole discretion. Use of residential facilities is subject to the rules and requirements of HEADstrong Foundation. All residents must sign a Nick’s House Guest Agreement, the form established by the HF. Length of stay is up to 6 weeks, extensions may be approved at the discretion of the board.
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The undersigned certifies to HF that he/she meets the eligibility requirements of the Nick’s House Residential Services Program, as described in this Application, and that all the information provide in or with this Application is true and correct.