A PREFERRED RESOURCE FOR LOCATING SENIOR CARE OPTIONS SINCE 1991

Define Care Needs

Complete this form to assist us in helping you locate the appropriate facility in your elderly loved one's city or nearby area.  Complete only the items that apply to your loved one.  All personal information you provide is held in strictest confidence and is not shared with advertisers or any other third party.

*=Required Field

SENIOR'S INDICATIVE INFORMATION:

Senior's Name:

*First:

*Last:

*Age:

*City:

*State:

SENIOR'S CURRENT RESIDENCE


PHYSICAL INFORMATION

Ambulation Level  

Wheelchair Transfer Assistance:

Needs Help With Activities Of Daily Living   (check all that apply)

Bathing

 

Dressing

 

Toileting

 

Incontinent   (check all that apply)

Bladder

 

Bowel

 

Wears Diapers

 


MEDICAL INFORMATION

Cognitive Impairment  (check all that apply)

Alzheimer's

 

Dementia

 

Short-term Memory Loss

 

Wanders

 

Diabetic   (check all that apply)

Controlled with Medications

 

Insulin Injections

 

Special Diet

 

Health Conditions   (check all that apply)

Heart Disease

 

History of Strokes

Parkinsons's Disease

 

Arthritis

Cancer

 

COPD



Additional Information Regarding Your Loved One's Needs and Your facility Search
(do not exceed 2000 characters)

 

RESPONSIBLE  PARTY  INFORMATION (*=required field)

*First name:

 

*Last name:

 

*Address 1:

 

*Address 2:

 

*City:

 

*State:

 

*Zip Code:

 

*Relationship to senior

 

*Primary phone #

 

*Cell phone #

 

*E-mail address:

 

*Facility Type:

Assisted Living Facility

 

Small Board and Care Home

 

Alzheimer's Secured Facility

 

Independent Living Facility

 

In-home Care

 

*Monthly Budget Range:

Minimum

 

Maximum

 


After we review this form, an Eldercare Consultant will contact you.

Please enter your email address and telephone number in order for us to contact you. Thank you!

 

1911 Douglas Blvd.,
Suite 85-198
Roseville, CA 95661
(Suburb of Sacramento)
Local:
(916) 783-8779
Email: info@eldercareservices.com
 copyright © 1997-2016 Elder Care Referral Services. All Rights Reserved