Kroontje Health Care Center • 1000 Litton Lane • Blacksburg, VA 24060 •(540)443-3415
This form must be completed all at once and cannot be saved to finish later. Please provide answers to all relevant questions on the following pages. If you have questions as you complete the forms, please call Linda Kirkner at 540-443-3415.
We work to protect the security of your information during transmission by using Secure Sockets Layer (SSL) software, which encrypts information you input.
Note: Prior to admission please provide the following documents- Social Security Card, Insurance Cards, POA/ guardianship Documents, Advance Medical Directives and DNR orders
Warm Hearth Village (WHV) strives to maintain a safe environment for all residents, visitors and staff by requiring a criminal background check prior to long-term residency effective May 1, 2016. A national criminal background check will be obtained for each applicant seeking residency at WHV regardless of level of care/service. WHV, via the admissions committee, will review the results of the background check and compare the results with the Department of Health "barrier crime” list. Applicants can be denied admission based on the number and severity of convictions listed on the background check. Any negative findings may be grounds for dismissal from care and services and/or denial of long-term residency. Applicants denied admission to WHV will be provided with a form stating the reason for the denial and a copy of the background check. Residents/clients denied admission to WHV may appeal by presenting a letter of request to the applicable Administrator/Director.