Assess Your Needs Form

Your First Name *

Your Last Name *

Your Phone Number *

Your Email Address *

Where are you seeking Care?

How quickly do you need to make a decision?

The senior in need of care is currently at

I'm seeking care at a

How many seniors are you seeking care for

1 2

I'm inquiring for my:

Senior in need of care

Gender

Yes

No

Gender

Yes

No

Is the senior or their spouse a Veteran?

Best describe their level of care needs

Do they require injections?

In order to get the care they need, this person:

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

Based on your budget, what's the MINIMUM class of community you are looking for?

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)

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)

Activity	Accomplishes Alone	Needs Some Help	Needs Much Help
Bathing
Getting Dressed
Feeding Self
Eating a nutritious diet
Walking
Using the toilet
Getting out of bed or a chair
Taking medications

Competency	Good	Moderate	Poor
Health
Mobility
Balance
Memory
Managing daily activities
Managing medications
Decision making
Managing finances

Unique Care	Yes
Needs an assistive device to get around (walker, wheelchair)?
Uses an electric scooter?
Has been diagnosed with Dementia or Alzheimer's Disease?
At risk of wandering or exiting without the needed supervision?
Takes medications for mental health issues (Bi-Polar, Schizophrenia, Depression)?
Needs help from a licensed professional to administer injections?
Has severe vision impairment or is blind?
Has severe hearing impairment or is deaf?
Can't control when they urinate?
Can't control when they have a bowel movement?
Uses a feeding tube?
Has a colostomy or pouch to collect waste from the body?
Has a urinary catheter?
Is a smoker?
Needs oxygen therapy or uses a device to get oxygen?
Needs a ventilator?
Has a tracheotomy tube?
Has a bandaged wound someone else needs to take care of?
Bedridden or bed bound?
Is overweight or obese?
Insists on bringing a small pet?

Any additional information you'd like us to know?