Living Well Services – Find the Right Level of Support
This short questionnaire helps us recommend the most suitable non-medical, independent living support for you or your loved one. Our focus is on structure, consistency, and daily living—not medical or hands-on personal care.
Who is this inquiry for?
Myself
Parent
Family Member
Other
Name of individual needing services
Age
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Where is the individual currently living?
Living alone
Living with family
Transitioning from hospital/rehab
Other
How would you describe their current daily routine?
Very structured and consistent
Some structure, but inconsistent
Little to no routine
Are there concerns about consistency, isolation, or lack of structure?
Yes
Some concerns
No
Is the individual able to manage the following independently? (Check all that apply)
Bathing
Dressing
Mobility
Personal hygiene
Does the individual require any of the following? (Check all that apply)
Medical or nursing care
Hands-on personal care
Memory care supervision
None of the above
What type of support would improve daily living? (Check all that apply)
Regular check-ins
Companionship and conversation
Help maintaining a consistent daily routine
Light household organization and structure
Accountability and guidance
Peace of mind for family
How often would support be most beneficial?
Occasional (1–2 times per week)
Consistent (3–5 times per week)
Daily structured support
Which best describes the level of support you are looking for?
Minimal support (occasional check-ins)
Moderate support (consistent weekly structure and support)
Higher-level support (frequent visits, routine guidance, and ongoing presence)
What are your primary goals? (Check all that apply)
Maintain independence at home
Improve daily structure and consistency
Reduce isolation or loneliness
Provide peace of mind for family
Avoid transition to assisted living
What would “living well” look like for you or your loved one?
What monthly investment range are you comfortable with for ongoing support services?
Under $1,000
$1,000 – $1,500
$1,500 – $2,200
$2,200 – $2,800
Open to recommendations based on needs
Please confirm the following:
I understand this is a non-medical support service
I understand services focus on routine, structure, and support—not personal care
I understand Magnolia does not provide financial assistance or funding
SUBMIT TO FIND THE BEST SUPPORT PLAN
Should be Empty: