Pre-Consultation Questionnaire
Client Information
First Name
Last Name
Age
Gender
Please Select
Male
Female
Primary Contact Name (leave blank if you are the client)
First Name
Last Name
Relationship to Client
Primary Contact Email Address
example@example.com
Primary Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Method of Contact
E-mail
Phone Call
Current Living Situation
Where is the client currently living?
Preferred number of bedrooms
Room Privacy Preference
Please Select
Private
Private with shared common areas
Semi-private
Shared Room
Undecided
What is your ideal timeline for moving?
Please Select
As soon as possible
1-3 months
3-6 months
6-12 months
Just looking for now
Do you need help selling your current home?
Yes
No
Preferred location(s):
What are the client's hobbies or interests?
Care Needs
Please check all that apply
None
Experiencing weight loss
Assistance transferring from bed
Requires mobility assistance
Medical equipment required
Assistance transferring from chair
Meal preparation assistance
Special diet
Feeding support
Hygiene support
Bladder control issues
Dressing support
Bowel control issues
Toileting support
Incontinence undergarments
Hearing issues
Vision issues
Other
Client's pertinent medical history:
Any additional notes or information you'd like us to know:
Submit
Should be Empty: