Please Fill and Send back so we can help you more effectively
Assessment Form
Your Full Name:
Primary Phone:
Secondary Phone:
Fax:
E mail:
What is your relationship to the senior?
Senior's Information
Senior's Name:
Primary Phone:
E mail:
Sex: M______ F______
Age:
Date of Birth: ______/_______/_______
Additional Person, if any:
Sex: M_____ F______
Age:
Date of Birth: ____/_______/______
Current residence: Home______ With Relative_______ Community________
If community, please indicate name:
Mobility:
No assistance_____ Walker_____ Cane_____ Wheelchair____ Scooter/Electric cart______ Bedridden______
Memory: Excellent/Sharp______ Forgetful______
Confused_______ Wanderer______
Special Needs?___________________________________
What type of Community are you looking for?
Continuing Care Retirement Community (CCRC)________
Independent Living_____________
Assisted Living ___________
Board and Care Home__________
Alzheimer's/Dementia Care_________
Skilled Nursing Facility__________
Type of Housing Required
Respite Care______
Studio_______
1 Bedroom______
2 Bedroom______
Shared______
Type of Ownership
Rent____
Own____
Monthly Budget $_________________________
Location
City:
1st choice__________________________________
2nd choice__________________________________
3rd choice__________________________________
Proximity to?___________________________________________________________
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
