Authorized Decision-Maker & Family Contact

This secure enrollment form is for the resident’s legally authorized representative, health care power of attorney, guardian, conservator, or other approved family contact. It records authority, contact preferences, communication priorities, emergency contacts, document availability, and the people who may receive advocacy updates. Do not send medical records, diagnoses, medication lists, insurance documents, photographs, or legal documents through ordinary Wix forms or email. Enrollment information must be completed through the secure IntakeQ/PracticeQ portal. A private portal link will be provided after the introductory conversation.