(1) Inquiry

CLIENT INQUIRY/INITIAL FORM

Please note that very few fields are required in this form so you can get started here as simply as possible and there is HIPPA compliant upload at the end, if you prefer to provide information that way instead of typing into this form.
I am a family member, relative, Power of Attorney, Guardian, Neighbor of the clientI work in healthcare/LTC industry. I am referring a client that I am not related to.I am filling this out for myself
Healthcare/LTC Industry Referral Name
Healthcare/LTC Industry Referral TITLE and Company
i.e. Case Manager, etc.
Healthcare/LTC Industry Referral Email
example@example.com
Healthcare/LTC Industry Referral Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Inquirer/Responsible Party Name
Responsible Party Name
Inquirer/Responsible Party Email
example@example.com
Responsible Party Email
example@example.com
Inquirer/Responsible Party Cell
Please enter a valid cell phone number.Format: (000) 000-0000.
Responsible Party Cell
Please enter a valid cell phone number.Format: (000) 000-0000.
Client Name*
(Senior Looking for Assistance/Resources)
Relationship*
i.e. son/daughter, POA, Guardian, Friend, or type in: SELF
Client Email
example@example.com
Landline
Cell
Gender
Age
Client Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Pronouns
Major Cross Streets
YesNo
Please enter gate code
YesNo
YesNo
Please describe the pet
Pets Names:
Are there Other Family Members or POAs or Guardians to note?
Siblings, etc.
Senior Living Advice/PlacementHome Assessments / Modifications * This requires Insurance Card Upload at End of FormLooking for Training/Educational ResourcesCare Navigation/SupportCognitive Stimulation/Memory SupportOther
Independent LivingAssisted Living/Board and CareMemory CarePersonal Home AloneLiving w/ Family/FriendOut of StateOther
Below, some of the questions only apply if you are inquiring about Senior Living Advice and Long Term Care Placement Services. If you are filling this out for other reasons, skip the quesitons that pertain to living/assisted living choices.
Projected Move In Date

MonthDayYear
Enter a date
Desired Location - Select here or use next field to type in
Location Desired
Large Community (11+ beds )Small Community (1-10 beds
Higher Care NeedsNot Satisfied w/ Current PlaceRelocatingUnfamiliar w/ Choices
Other
Under $2,000$2,001 to $3,500$3,501 to $5,000$5,001 to $7,000$7,000 plusOther
SSSSIVA Aid & AttendancePension/RetirementLTC InsuranceMedicaid (not filed)Medicaid (HCBW approved)Family will ContributeI need help to figure it outClient/Family will need help figuring it out
YesNo
Type VA Benefits Claimed
i.e. Pension, Aid In Attendance, etc.
Special Instructions
Explain Current Situation
If need to
Interests, Hobbies
Cultural/Spiritual/Religious/Affiliation
Notes
How did you hear about us*
i.e. Word of Mouth, Internet, Someone's name
If SRN Filled This From Out, please select:
Date of Inquiry*

MonthDayYear
Date
This is a HIPPA compliant Upload: You may upload as much or as little as you are able/willing at this time. For Placement, now or eventually, the following is going to be needed: HNP/Physical, TB Test, Picture ID, Insurance Cards, POA/Guardianship Documentation. For Home Safety Assessment, please upload Insurance Card (front and back) at the time of filling out this form.

Case Managers/Referral Partners: please upload HNP, TB, Face Sheet, etc.
Cancelof
This is a HIPPA compliant Upload: For all Home Safety Modification requests, your Insurance cards are required.*

Insurance Cards
Cancelof
Should be Empty:

CLIENT INQUIRY/INITIAL FORM