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Senior Independent Living

Assess Your Needs Today

We values your privacy and that of your loved one(s). The information that you send to us via this assessment form will be treated as strictly confidential by our company and by the senior assisted or independent living communities that we contact on your behalf.

Fill out the following form to have your information sent directly to one of our placement specialits. They will then contact you concerning your request for assistance. Please be as complete as possible. This will enable our specialists to best match your needs to senior living communities. Items in red are required.

Your Contact Information
Your Full Name:
Your Address:
City:
State:
5 Digit Zip:
Secondary Contact:
Primary Phone:
Secondary Phone:
Fax:
Email Address:
What is your relationship to the senior?:

Senior's Information
Senior's Name:
Sex: F M
Age:
Date of Birth: (mm/dd/yyyy)
Additional Person, if any:
Sex: F M
Age:
Date of Birth: (mm/dd/yyyy)
Current Residence: Home With Relatives Community
If community, please indicate name:
Medical Diagnosis
Alzheimer's Hypertension
Cancer Kidney Disease
Dementia Mental Illness
Depression Parkinson's
Diabetes Stroke
Emphysema TIAs
Heart Disease
Congestive Heart Disease
Macular Degeneration
Other?

Assistance Needed
NoneSomeFull
Walking
Bathing / Showering
Grooming
Eating
Catheter
Colostomy
Medicating
Toileting
Injections
Dressing
Incontinence
Mobility
No Assistance Electric cart
Cane Walker
Bedridden Wheelchair

Memory
Like a Steel Trap Forgetful
Confused Wanderer
Other:
Aphasia
Oxygen
Pet(s) - Weight lbs.
Self Sufficient
Smoker
IV
Tube Feeding

Vision/Sight
Legally BlindPartially SightedGood Vision

Hearing
DeafPartial HearingGood Hearing

Additional Information
What type of Communities are you looking for: Continuing Care Retirement Community
Independent Living
Assisted Living
Board & Care Home
Alzheimer's/Dementia
Skilled Nursing Facility
Locked Facility
Respite Care
Type of Room Desired?: Studio
1 Bed
2 Bed
3 Bed
Shared
What is the monthly budget
Location - Choice 1
State Desired
City or Cities
Zip Code (if avail)
Location - Choice 2
State Desired
City or Cities
Zip Code (if avail)
Location - Choice 3
State Desired
City or Cities
Zip Code (if avail)
 
How soon do you need placement?
How did you hear about Senior Transitions?
Other?
When is the best time for us to call? Anytime
Morning
Aftenoon
Evening
May a community send you a brochure? Yes No
 
To expedite our service to you, please indicate any communities you have toured or contacted (to avoid duplication):
 
What circumstances have led you to consider senior/assisted living?:



Form v. 2/07