Contact Information

Name:

Prospective Client Name:

Home Phone:

Cell Phone:

Email Address:

Comments:

Additional (Optional) Information:

What type of accommodations are you looking for? (select all that apply)

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

Does the prospective client use any assistive devices? (select all that apply)

CaneWalkerWheelchairElectric Wheelchair-ScooterOther

Do they require assistance with any of the following? (select all that apply)

BathingEatingTranferringToiletingMedicationsWalking or ambulation

Does the senior suffer from any of the following? (select all that apply)

Impaired VisionIncontinenceHearing DeficitsFalling

Does the senior suffer from any memory impairment? (select all that apply)

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

What is the monthly budget or price range being considered? (select all that apply)

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

Is ALTCS (Medicaid planning) a likelihood or necessity?
YesNo