July-06-2008 12:06:37 PM


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Please fill out this quick assessment form to find a quality care facility in your area. Our caring and experienced family advisors are available 7 days a week, at no charge, to help you make the best choice for your loved one.
Your Contact Information (*indicates required fields)
*Your First Name Last Name
Address 1City
Address 2Zip
State Cell#
Relationship
  to elder
*Evening#
*Daytime# *Email
Please include area codes with all the contact numbers
Senior's Information:
*First Name Last Name
Age City
State Zip
Please list three (3) cities where eldercare services are desired:
What level of assistance does your loved one need?
*Taking Medications *Bathing / Showering *Using the Toilet
Does your loved one experience any memory loss?
None Some Dementia Alzheimers Wanderer
Can they walk unassisted: Yes No
Use a cane Use a walker In wheelchair Need help transfering
Note: Medicare and Medi-cal do not pay for residential assisted living costs.
Are you interested in Long Term Care?
Private or shared room?
*Have your contacted any other referral agencies yes no
Have your toured any homes on your own? yes no
Monthly Budget Range:
Minimum Budget:
Maximum Budget:
Additional information regarding your search