Check the following services if assistance will be needed:
Ambulation - If yes, using: Walker Wheelchair
Transferring Assistance Yes - They can assist Yes - But they can not assist
Assistance Services - Check all that apply Meal Preparation Medication Assistance Taking Showers or Baths Dressing Themselves Assistance with Eating Hygiene Assistance
Incontinence Bladder Bowel
Do They Wear Depends? Yes No Not Sure
Cognitive Level:
Is there any experience of a loss of memory? -- Please select -- No memory loss Sometimes forgetful Moderate memory loss Advanced memory loss
If so, are there any problems with wandering? Yes No Not Sure
Check all current health conditions that are applicable: Arthritis Diabetes Heart Disease Stroke/TIA Anxiety Alzheimer's / Dementia Parkinson's Disease TBI Cancer Depression
What is the monthly budget available to cover this care?
Minimum Budget -- Please select -- Under $1500 $2000 - $2500 $3000 - $3500 $4000 or more
Maximum Budget -- Please select -- Under $1500 $2000 - $2500 $3000 - $3500 $4000 or more
Are they one of the following: Veteran Spouse Vet Long Term Care Insurance
Information about the person this search is for:
Name of the person needing care:
This person is related to me as: -- Please select -- Self Parent Spouse Relative Friend Client Other
What is their age:
They are currently residing at: -- Please select -- Home Home with some help Home with family Independent or Assisted living Board and Care Home Nursing Home
How soon will care be needed? -- Please select -- 1- 2 Days 2 - 7 Days 1 - 3 Weeks 1 Month 1 - 3 Months Not Sure
What type of care is of most interest? -- Please select -- In Home Care Independent Living Assisted Living Board and Care Home Memory Care Not Sure
I would like to find care for this person in or near the area of:
State: -- Please select -- California Outside of California
Additional information about the person inquiring:
First Name of the Inquirer
Last Name of the Inquirer
Phone Number: *
Email Address *
Best way to reach you: * -- Please select -- Email Phone
How did you hear about us: * -- Please select -- Healthcare Professional Family or Friend Newspaper or Magazine Radio
Additional Questions/Comments
Yes, please send me your brochure
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