Assess Your Needs Today

We values your privacy and that of your loved one(s). The information that you send to us via this assessment form will be treated as strictly confidential by our company and by the senior assisted or independent living communities that we contact on your behalf.

Fill out the following form to have your information sent directly to one of our placement specialits. They will then contact you concerning your request for assistance. Please be as complete as possible. This will enable our specialists to best match your needs to senior living communities. Items in red are required.

Your Contact Information

Your Full Name:

Your Address:

City:

State:

5 Digit Zip:

Secondary Contact:

Primary Phone:

Secondary Phone:

Fax:

Email Address:

What is your relationship to the senior?:

Senior's Information

Senior's Name:

Sex:

F M

Age:

Date of Birth:

(mm/dd/yyyy)

Additional Person, if any:

Sex:

F M

Age:

Date of Birth:

(mm/dd/yyyy)

Current Residence:

Home With Relatives Community

If community, please indicate name:

Medical Diagnosis

Alzheimer's	Hypertension
Cancer	Kidney Disease
Dementia	Mental Illness
Depression	Parkinson's
Diabetes	Stroke
Emphysema	TIAs
Heart Disease
Congestive Heart Disease
Macular Degeneration
Other?

	Assistance Needed
	None	Some	Full
Walking
Bathing / Showering
Grooming
Eating
Catheter
Colostomy
Medicating
Toileting
Injections
Dressing
Incontinence

Mobility

No Assistance	Electric cart
Cane	Walker
Bedridden	Wheelchair

Memory

Like a Steel Trap	Forgetful
Confused	Wanderer

Other:

Aphasia

Oxygen

Pet(s) - Weight lbs.

Self Sufficient

Smoker

Tube Feeding

Vision/Sight
Legally Blind	Partially Sighted	Good Vision

Hearing
Deaf	Partial Hearing	Good Hearing

Additional Information

What type of Communities are you looking for:

Continuing Care Retirement Community
Independent Living
Assisted Living
Board & Care Home
Alzheimer's/Dementia
Skilled Nursing Facility
Locked Facility
Respite Care

Type of Room Desired?:

Studio
1 Bed
2 Bed
3 Bed
Shared

What is the monthly budget

Location - Choice 1

State Desired

City or Cities

Zip Code (if avail)

Location - Choice 2

State Desired

City or Cities

Zip Code (if avail)

Location - Choice 3

State Desired

City or Cities

Zip Code (if avail)

How soon do you need placement?

How did you hear about Us?

Other?

When is the best time for us to call?

Anytime
Morning
Aftenoon
Evening

May a community send you a brochure?

Yes No

To expedite our service to you, please indicate any communities you have toured or contacted (to avoid duplication):

What circumstances have led you to consider senior/assisted living?:

NEW RESEARCH

The National Institute on Aging (NIA), part of the National Institutes of Health (NIH), is the lead Federal agency for Alzheimer's Disease research. NIA-supported scientists are testing a number of drugs to see if they prevent AD, slow the disease, or help reduce symptoms. Researchers undertake clinical trials to learn whether treatments that appear promising actually are safe & effective in people.