Logan Acres Senior Community Information Request Form

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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? *

Yes No

6. Are you or your loved one completely dependent upon others for your toileting needs? *

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? *

Yes No

10. Do you or your loved one become anxious, combative or verbally or physically abusive? *

Yes No

11. Are you or your loved one unable to walk alone? *

Yes No

12. Have you or your loved one had multiple falls? *

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

Logan Acres Senior Community
2739 County Road 91
Bellefontaine, OH 43311
(937) 592-2901

The Homestead Logan Acres
2745 County Road 91
Bellefontaine, OH 43311
(937) 599-7077

This institution is an equal opportunity provider and employer.

Website by Berry Digital Solutions, LLC
West Liberty, Ohio

HOME
ABOUT US
SERVICES
EMPLOYMENT
CONTACT US
- INFO REQUEST FORM

What Level of care is right for you or your loved one?

Information Request Form​

Information Request Form