Personal Information

First Name *

Middle Name

Last Name *

Other name (as on Medicare card?)

Example: maiden name, hyphenated name, different spelling.

Date of Birth *

Address *

State *

City *

Zip Code *

Did someone recommend you?

Mobile Phone *

Email Address

Representative / Who is signing for Resident?

Insurance & Coverage

Technology & Home Environment

Do you have Wi-Fi in your home? *

Yes No

How do you get your TV?

Medications and Medical History

Please list the medications you are currently taking

Social & Behavioral Health

Behavioral health for seniors focuses on your emotional, mental, and social well-being. As we age, changes in our health, daily routine, or social support can affect how we feel. Some common concerns include feeling sad or worried, changes in memory, or feeling more alone than usual. These issues are very common, and they can affect your mood, your energy, and even your physical health.

The good news is that help is available—and it can make a big difference. Talking with a caring professional, getting support with medications (if needed), and staying connected can greatly improve your quality of life.

Silver Rise – RAK Health Care Services offers confidential, supportive care to help you feel your best. We can connect you with someone who will listen, understand your concerns, and guide you—right from the comfort of your home. This service is a Medicare-covered benefit.

We’re here to support you every step of the way. *

Please provide me with this benefit. I do not want this benefit even if I am elegible.

Consent & Confidentiality

Signature

Patient or Patient Representative Signature *

Typing your name here is considered an electronic signature.

All fields are securely submitted. Please review before submitting.

Thanks for reaching out!

We’ve received your request and will get back to you soon.