Logan Acres Senior Community Information Request Form

Please answer the following questions so we can help determine which level of care we provide is right for you.

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.

If requesting info on behalf of someone else, please list their name and your relationship to that person.

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