Please Fill and Send back so we can help you more effectively
Your Full Name:
What is your relationship to the senior?
Sex: M______ F______
Date of Birth: ______/_______/_______
Additional Person, if any:
Sex: M_____ F______
Date of Birth: ____/_______/______
Current residence: Home______ With Relative_______ Community________
If community, please indicate name:
No assistance_____ Walker_____ Cane_____ Wheelchair____ Scooter/Electric cart______ Bedridden______
Memory: Excellent/Sharp______ Forgetful______
What type of Community are you looking for?
Continuing Care Retirement Community (CCRC)________
Assisted Living ___________
Board and Care Home__________
Skilled Nursing Facility__________
Type of Housing Required
Type of Ownership
Monthly Budget $_________________________
What is your time frame? How soon do you need placement?
*In most cases our fees are paid for by the communities. There are some communities that will not pay our compensation. To best serve you and your interests, would you be willing to pay our compensation, (typically, 1 months rent,) should you choose a community that does not participate? Yes______ No______
To better serve you, any detailed and specific information would help us assist you in your search for the right home
* Placement Services are Provided at no charge to you or your family. We are compensated by the communities