480-969-9449

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    Additional (Optional) Information:

    Alzheimers-Dementia CareAssisted Living FacilityAdult Group HomeIndependent Senior Living CommunityNot Sure

    CaneWalkerWheelchairElectric Wheelchair-ScooterOther

    BathingEatingTranferringToiletingMedicationsWalking or ambulation

    Impaired VisionIncontinenceHearing DeficitsFalling

    No the senior is alert and orientedSome short term lossModerate short term loss and some long term lossDiagnosed with severe type of dementia

    $1500-$1999$2000-$2499$2500-$2999$3000-$3499$3500-$3999$4000+


    YesNo