Resident Application

  • Please provide the following information, which will be kept confidential and is required for anyone applying to become a resident of a Goodwin House community and/or a member of Goodwin House at Home. In addition to this form, please submit the Confidential Financial Statement included in your application packet. There is a non-refundable application fee of $300 per person. For applications to Goodwin House Alexandria and Goodwin House Bailey’s Crossroads, please also include an additional deposit of $1,000 to join our list of prospective residents called the Priority Club. If at any time you wish to be removed from our list, please submit a request in writing, and we will refund your $1,000 deposit.
    Residency at a Goodwin House community and/or membership of Goodwin House at Home will be conditioned upon a satisfactory medical report and in-person assessment. You can be a member of Goodwin House at Home while remaining on the Priority Club list.

























  • Family Information: First Person

    Below, please list close relatives or friends. For each individual, please select yes or no if you consent to allow Goodwin House to share information about your application with them.






















































  • Medical & Insurance Information: First Person


































































  • Family Information: Second Person

    Below, please list close relatives or friends. For each individual, please select yes or no if you consent to allow Goodwin House to share information about your application with them.






















































  • Medical & Insurance Information: Second Person









































  • Emergency Contacts

    Whom should we notify in case of an emergency?


















































  • More Details





  • Payment of Application Fee


























    The application fees are non-refundable. The $1000 priority list deposit is refundable if you do not move in; however, we will need to refund your deposit by check and cannot credit the amount back to your credit card.
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  • Signature

  • I do hereby submit this application to be considered for admission to a Goodwin House community, or Goodwin House at Home.

To complete your application please download and complete the three following documents: the Confidential Financial Statement, the Notice of Privacy Practices (HIPPA) Form, and the Sex Offender Registry Notification. Once completed please print and mail all three to Carol Opiela, 4800 Fillmore Avenue, Alexandria, VA 22311.

Confidential Financial Statement

Notice of Privacy Practices

Sex Offender Registry Notification

 

 

This site is setup to accept application fees and Priority Club deposits.  Any refunds will be returned by check and there are no products to be shipped.