Assess Your Needs

How to Contact You*indicates required fields

• Your First Name*
• Your Last Name*
• Your Phone Number*
• Your Email Address*

Preferences

• Where are you seeking Care?
• How quickly do you need to make a decision? Immediately 1 to 2 weeks 3 to 4 weeks Within the next 3 months Over the next year Not sure
• The senior in need of care is currently at: a hospital a rehab facility home alone home with a spouse or caregiver a family member/friends' home a senior community
• I’m seeking care at a: Retirement/Independent Living Community Assisted Living Community In-Home Care Skilled Nursing Facility Not Sure

About Your Loved One

• How many seniors are you seeking care for:
  1 2
• I’m inquiring for my: Spouse Mother/Father Daughter/Son Sibling/Family Patient/Client Friend Other
• Senior in need of care:
  Gender Male Female
  Gender Male Female
• Is the senior or their spouse a Veteran? Yes No Not sure
• Best describe their level of care needs: Independent Needs some weekly assistance Needs some daily assistance Needs considerable daily assistance Completely dependent End-of-life or hospice care
• Do they require injections? Yes No Unsure
• In order to get the care they need, this person: ...is willing to move out of their home and into a facility ...prefers not to move out of their home and into a facility ...is not willing to move out of their home ...has no preference about where they receive care
• What are the biggest challenges you will face
  in making the transition? (select all that apply)
  Paying for adequate care Convincing my loved one that a change is required Getting all family members in agreement on what to do Finding the right facility that meets my loved one's unique needs Other

Budget

• Based on your budget, what’s the MINIMUM class of community you are looking for? High-end Upper moderate Moderate Lower-end
• Please select your MAXIMUM PER PERSON monthly budget? (This will not stop us from finding lower cost options as long as they can provide adequate care for your loved one’s needs) $5,000+ up to $5,000 up to $4,500 up to $4,000 up to $3,500 up to $3,000 up to $2,500 up to $2,000 up to $1,500
• What funding source(s) do you plan to use to cover the senior living costs? (select all that apply)
  Private funds (income or savings) Long-term care insurance TRICARE (military) Medicare/Medi-Cal Supplemental Security Income (SSI)

Any additional information you’d like us to know?