Senior Name:
Age:
Where is your senior currently living?:
--None--
Home
Home (with Home Care Services)
Hospital
Assisted Living
Independent/Retirement Living
Nursing Home
With Family
Senior Health Information:
Dementia/Alzheimer's:
--None--
Yes
No
Mobility:
--None--
Can Walk by herself/himself
Uses a cane
Uses a walker
Uses a wheelchair
Not mobile
Senior Financial Information:
Financial Resources:
--None--
Private Pay
Private Insurance
Medicare
Medi-Cal
Social Security Only
Supplemental Security Income(SSI)
Social Security Disability Insurance (SSDI)
Able to afford per month:
--None--
Less than $1,000
$1,000-$1,500
$1,500-$2,000
$2,000-$2,500
$2,500-$3,000
$3,000-$3,500
$3,500-Over
Daily Activity Help:
Getting dressed:
--None--
Yes
No
Taking a bath or shower/Grooming:
--None--
Yes
No
Medication Management:
--None--
Yes
No
Able to feed self:
--None--
Yes
No
Wearing Diapers:
--None--
Yes
No
Preferences:
Type of Senior Care Community you would like for your Southern California Senior:
--None--
Assisted Living
Assisted or Board And Care
Independent/Retirement Living
Senior Apartment
Continuing Care (CCRC)
Alzheimers/Dementia community
Board and Care Home
Nursing Home
Secured Community
Home Care
Adult Residential Facility
Other
Type of Living Area Desired:
--None--
Private Studio
Private One bedroom
Two bedroom
Shared Room
I would like for the senior community to offer:
--None--
Activities
Community Trips
Pets Allowed
Smoking
Kitchen
Parking for Residents
Chinese/Mandarin Speaking Residents
Would you like brochures and pricing from the communities that may be a good match for your search?:
--None--
Yes
No
Desired location of new home: (ex. Los Angeles, CA)
Make Sure You give us Your Information:
Salutation:
--None--
Mr.
Ms.
Mrs.
Dr.
Prof.
Title:
First Name:
*
Last Name:
*
Email: *
Phone:
*
Work Phone: *
Mobile Phone:
Address:
City:
State:
Zip:
How Senior is related to you:
--None--
Son or Daughter
Grandchild
Spouse
Self
Sibling
In Law
Aunt or Uncle
Niece or Nephew
Friend
Power of Attorney
Professional
Other
I found Southern California Senior Resources via:
--None--
Advertising
Internet
Healthcare Professional
Friend or Family member
Newspaper article
Other
How quickly are you looking for senior housing?:
--None--
Less than 1 week
1-2 weeks
One Month
2-4 Months
6 Month - 1 Year
Unsure
Please tell us what has prompted you to contact Southern California Senior Resources and if there is any additional information that will assist us in our search on your behalf:
BEFORE YOU CLICK ON SUBMIT - make sure you have entered in your first and last name , your e-mail address , your home and work telephone numbers so we can help you.
All our services are free and all of your information is confidential.
If you do not enter in the required information - we will not be able to contact you.
