Care Assessment
Please fill out the following form. This form allows us to get to know you better so we can find the best senior living community that will meet your care needs and lifestyle preferences.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Who is in need of care?
Myself
My parent(s)
A relative
Other
What is(are) their name(s)?
How old is(are) the individual(s) in need of care?
Gender?
Male
Female
Couple
Other
Current living situation? (Click all that apply)
Lives with spouse / significant other
Lives alone with no assistance
Lives alone with caretaker assistance
Lives with family / caretaker
Other
Please enter their height:
Please enter their weight:
Please select if your loved one has any of the following:
Power of Attorney Financial
Power of Attorney Medical
Guardian
None
If your loved one has a POA or Guardian, please enter their name below:
What type of care are you interested in? (Click all that apply)
Assisted Living
Nursing Home
In-Home Care
Adult Day Care
Sitter / Companion Services
Physical, occupational, speech therapy
Please select the home environment(s) that interest you the most.
5 Star Hotel
Like Home
Please indicate options that you would like to have available in your new community.
24 hour nurse on-site
Fitness Center
Salon / Barber Shop
Chapel
Movie Theatre
Game Room
Bar
Culinary Chef
Restaurant Style Dining
Please type the zip code(s) or the general location of the area you are interested in residing.
Services needed? (Click all that apply)
Bathing
Dressing
Grooming
Toileting
Eating
Medication Management
Memory Care
Transfer Needs: (Click all that apply)
No assistance needed
Needs assistance getting in/out of chair
Needs help getting in/out of bed
Needs assistance getting in/out of shower
Do they require any of the following equipment? (Click all that apply)
Wheelchair
Walker
Cane
Other
Toileting Needs: (Click all that apply)
No assistance needed
Need help transferring to commode
Adult briefs (no assistance changing)
Adult briefs (needs assistance changing)
Bedside commode
Catheter
Ostomy
Other
Grooming: (Click all that apply)
Shaving
Combing hair
Brushing teeth
Lotion / skin care application
Nails clipped
None
Other
Bathing: (Click all that apply)
Shower set-up
Assistance getting in/out of shower (tub)
Hair shampooing
Body Washing
None
Other
If you'd like to do an at home memory assessment, please copy and paste the link below to locate the Mini-Mental State Examination (MMSE). Once completed, please upload here: http://www.fammed.usouthal.edu/Guides&JobAids/Geriatric/MMSE.pdf
Browse Files
Drag and drop files here
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of
Please select memory diagnosis (if any):
Alzheimer's
Dementia
Other
Memory:
Very alert and oriented
Mostly alert and oriented, but sometimes forgetful
Oftentimes forgetful
Extremely forgetful and not oriented to day and or time
Other
If there is memory loss, please select all that apply:
Wandering
Combativeness
Yelling / Shouting
Aggression
Sundowners
Unoriented to time and or day
Sexual inappropriateness
Other
Please select any of the following that apply:
Insulin Dependent Diabetic
On 24 Hour Oxygen
Tracheostomy
Ventilator
Dialysis
None
What activities / hobbies do they enjoy?
If your loved one has any peculiar habits or routines that a caregiver should be aware of, please explain below:
Do they have any pets? (Click all that apply)
Dog
Cat
Bird / fish / small caged animal
Other
Are you able to care for your own pet, or will you need assistance caring for your pet?
I am able to care for my own pet.
I will need assistance caring for my pet.
Were they or their spouse in the military?
Yes
No
Were they or their spouse in an active war while serving in the military?
Yes
No
How do they plan to pay for their placement needs? (Click all that apply)
Self pay
Family contributions
Long term care insurance
Medicaid
Medical insurance
VA Aid
What is their approximate monthly budget?
Less than $2,000
$2,000 - $2,999
$3,000 - $3,999
$4,000 - $4,999
$5,000 - $5,999
$6,000 - $6,999
$7,000 - $7,999
$8,000 - $8,999
$9,000 and up
I don't know
Do you have a home you will be selling when you transition into an assisted living community?
Yes
No
Please tell us anything else you feel we need to know to assist with their placement.
What is your preferred method of contact?
Phone Call
Text Message
Email
If there are any additional family members you'd like to share email communications with, please enter their email address below:
example@example.com
example@example.com
example@example.com
Submit
Should be Empty: