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INFO REQUEST FORM
What Level of care is right for you or your loved one?
Information Request Form
Please answer the following questions so we can help determine which level of care we provide is right for you.
*
Indicates required field
1. Are you or your loved one completely dependent upon someone to move about in your residence or the community?
*
Yes
No
2. Do you or your loved one require constant supervision when eating or must be fed by others?
*
Yes
No
3. Are you or your loved one completely dependent upon others for dressing?
*
Yes
No
4. Do you or your loved one require total daily assistance for your hygiene and grooming?
*
Yes
No
5. Are you or your loved one completely dependent upon others for bathing/showering?
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Yes
No
6. Are you or your loved one completely dependent upon others for your toileting needs?
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Yes
No
7. Are you or loved one unable to safely handle medications?
*
Yes
No
8. Have you or your loved one been diagnosed with a terminal illness that requires constant care?
*
Yes
No
9. Is your loved one disoriented to person, place and time?
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Yes
No
10. Do you or your loved one become anxious, combative or verbally or physically abusive?
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Yes
No
11. Are you or your loved one unable to walk alone?
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Yes
No
12. Have you or your loved one had multiple falls?
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Yes
No
13. Do you or your loved one receive Medicaid benefits in the community?
*
Yes
No
Please provide your information below so we have a way to contact you.
Name
*
First
Last
This inquiry is for:
*
Myself
A loved one
If requesting info on behalf of someone else, please list their name and your relationship to that person.
Name of Person Requesting Info For
*
First
Last
Your relationship to person you're requesting info for:
*
Phone Number
*
Email
*
Questions/Comments?
*
I agree to receiving marketing and promotional materials
Submit
HOME
ABOUT US
OUR LEGACY
OUR TEAM
OUR MISSION
RESOURCES
SERVICES
THERAPY
LONG TERM CARE
APARTMENT LIVING WITH ASSISTANCE
NEWS & EVENTS
GIVE A GIFT
EMPLOYMENT
CONTACT US
INFO REQUEST FORM
