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PROSPECTIVE CLIENT / RESIDENT PROFILE & INFORMATION
Please Complete Form Below So We May Better Assist You
HAVE YOU WORKED WITH ANY OTHER PLACEMENT SERVICE?(Online or Other)
YES
NO
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ON MEDICAID LONG TERM CARE INSURANCE? (or planning to):
YES
NO
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VETERAN
YES
NO
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SPOUSE OF VETERAN
YES
NO
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ACTIVE DURING WAR TIME?
YES
NO
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WHAT KIND OF ACCOMMODATIONS ARE YOU INTERESTED IN?
Independent Living Apartment
Assisted Living Facility
Memory Care Community
Adult Family Care Home (Residential Care Home)
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DOES YOUR LOVED ONE USE A...
Cane
Walker
Wheelchair
Independent
DO THEY REQUIRE ASSISTANCE WITH ANY OF THE FOLLOWING?
Dressing
Bathing
Eating
Toileting
Walking
Getting Out of Bed
Taking Medication
DOES YOUR LOVED ONE SUFFER FROM ANY OF THE FOLLOWING?
Incontinence
Low Vision
Speech
Hearing
Decreased Mobility
Oxygen Dependent
Diabetic Insulin Dependent
DOES YOUR FAMILY MEMBER SUFFER FROM ANY MEMORY IMPAIRMENT?
Some Short Term Memory Loss
Severe Memory Loss (Diagnosed with Dementia / Alzheimer's)
No. Alert & Oriented
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DOES YOUR FAMILY PREFER A ROOM THAT IS:
Semi-Private
Private
Studio
1 Bedroom
2 Bedroom
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