Exceptional staff providing exceptional care.
Home
Floor Plans
Gallery
News/Events
Schedule Tour
Contact Us
Exceptional staff providing exceptional care.
Home
Floor Plans
Gallery
News/Events
Schedule Tour
Contact Us
Questionnaire
Home
Questionnaire
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Who is in need of senior care?
Spouse
Parent
Myself
Someone else
What is the age of the person?
Where are they (or you) currently living?
Home (lives alone)
Home (lives with someone)
Assisted Living
Hospital
Nursing Home / Rehab Facility
How are they getting around?
Independent
Walker
Wheelchair
Cane
Immobile
Bedridden
of of you)
Do they need assistance with any of the following? (Select all that apply)
Medication
Toileting
Bathing
Diabetic care
Special diet
Housekeeping
Social activities
None
Have they experienced any of these behaviors?
Wandering
Aggressiveness
Hallucinations
Withdrawal
Sundowning
Judgement loss
Inappropriateness
24-hour care
Exit Seeking
None
Are they currently experiencing memory loss?
Yes
No
What are your room preferences?
Studio
One bedroom
Two bedroom
What is the total cost per month you believe you can afford?
Less than $2,000
$2,000-$5,000
$5,000-$7,000
More than $7,000
Are they (or you) a veteran?
Yes
No
How do they (or you) plan to pay for care?
Retirement
Family support
Home to sell
Insurance
VA Benefits
Other
How quickly do you need to find care?
Immediately
Within 30 days
Within 60 days
No rush – just preparing
Name
*
First
Last
Email
*
Phone
Submit
Help us understand your situation better and answer a few questions
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Who is in need of senior care?
Spouse
Parent
Myself
Someone else
What is the age of the person?
Where are they (or you) currently living?
Home (lives alone)
Home (lives with someone)
Assisted Living
Hospital
Nursing Home / Rehab Facility
How are they getting around?
Independent
Walker
Wheelchair
Cane
Immobile
Bedridden
Do they need assistance with any of the following? (Select all that apply)
Medication
Toileting
Bathing
Diabetic care
Special diet
Housekeeping
Social activities
None
Have they experienced any of these behaviors?
Wandering
Aggressiveness
Hallucinations
Withdrawal
Sundowning
Judgement loss
Inappropriateness
24-hour care
Exit Seeking
None
Are they currently experiencing memory loss?
Yes
No
What are your room preferences?
Studio
One bedroom
Two bedroom
What is the total cost per month you believe you can afford?
Less than $2,000
$2,000-$5,000
$5,000-$7,000
More than $7,000
find the you)
Are they (or you) a veteran?
Yes
No
How do they (or you) plan to pay for care?
Retirement
Family support
Home to sell
Insurance
VA Benefits
Other
How quickly do you need to find care?
Immediately
Within 30 days
Within 60 days
No rush - just preparing
Name
*
First
Last
Email
*
Phone
Submit
×