Individual Completing Form
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Email
*
Relationship to Senior
What type of placement are you seeking?
What type of facility are you interested in?
*
Is the senior currently in one of the following facilities?
Are you working with a social worker or case manager?
Have you contacted or toured any facilities?
Name of Senior
First Name
Last Name
Address of Senior
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Age of Senior
Is there a Power of Attorney for Finances? If yes, who?
Is there a Healthcare Proxy or Medical Power of Attorney? If yes, who?
Is the senior a veteran or spouse of a veteran?
What is your monthly budget for placement?
Would you describe the senior as more introverted or extroverted?
What hobbies and activities does the senior enjoy?
Mobility
Independent without device
Independent with device
Requires supervision or assistance while ambulating
Requires supervision or assistance for uneven surfaces, stairs, or transfers to toilet or shower
Is dependent on others for mobility
Requires a mechanical lift
Approximately how many medications is the senior currently taking?
Medication Management
Is the senior taking any medications that are injected?
Does the individual require routine care such as infusions, dialysis, or lab work?
Cognitive Status
Check all that apply
