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March-11-2010 10:20:52 AM
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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.
ASSESSMENT FORM
Your Contact Information
(*indicates required fields)
*Your First Name
Last Name
Address
City
State
Zip
Home Phone
*Cell Phone
*Valid Email Address
Relationship to Elder
(s)
Senior's Information
Note: Medicare and Medi-cal do not pay for residential assisted living costs.
*First Name
Last Name
Age
Bathing Assistance
Select Assistance
None
Some
Full
Dressing Assistance
Select Assistance
None
Some
Full
Taking Medications
Select Assistance
None
Some
Full
Mobility
Select One
Uses a cane
Walker
Wheelchair
Non-ambulatory
Using the Toilet
Select Assistance
None
Some
Full
Memory loss
Select one
None
Some
Dementia
Alzheimers
Wanderer
*Monthly Budget
City Choices
*
*Have you contacted other agencies
Yes
No
Additional Comments
If you do not enter in the required information-our advisor will not be able to contact you.
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