Start Your Senior Care Journey "*" indicates required fields NameThis field is for validation purposes and should be left unchanged.Name of person completing form*Relationship to patient (self, family, other)Phone Number*Email Address* Who is care being sought for? (self or loved one)Can the individual be left alone safely?Level of assistance needed (full, partial, independent)*Requires regular contact/supervision?*Safe to be home alone for 24 hours?High fall risk?Mobility Walks independently Uses cane Uses walker Uses wheelchair Can evacuate in emergency? Requires assistance to move? Requires total assistance? Nutrition Eats regular meals without help? Needs assistance with meals? Mental state Normal for age Occasional forgetfulness Frequent confusion Diagnosed dementia/memory care needs Toileting Independent Needs some assistance Needs total assistance Communication Able to call emergency numbers? Able to use phone? Needs communication support? Medication management Manages own medications Needs reminders/assistance Needs total medication management Bathing & grooming Independent Needs some assistance Needs total assistance Managing finances Handles own finances Needs assistance Needs full management Preferred type/size of community Small home (max 4-6 residents) Mid-size community (16-40 residents) Large community (100+ residents) In-home care preferred (agent/caregiver at home) Memory care needs?Preferred location or areasStyle of living preferred (social/active, quiet/private, pet-friendly, other)Additional notes or concerns
