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First name
*
Last name
*
Email
*
Phone
*
Which of the following are most important to your when selecting a community for a senior in your life?
Community & social life
Activities & classes
Health & wellness
Maintenance free living
Restaurant style dining
Location & neigborhood
I want to find the best living choice for:
Myself
My parent
My spouse
A patient
Someone else
Do they require in-home support 24 hours a day?
Yes
No
Are they experiencing any of the following that impact their ability to care for themselves?
Trouble seeing
Hearing loss
Difficulty eating
Difficulty walking
Depression
Falling or unsteadiness
Have they stayed in any of the following in the last 6 months?
Hospital
Rehab/Skilled nursing
Assisted living
In-patient stay
Do they need somone to help them with any of the following?
Getting dressed
Bathing
Using the bathrooom
Preparing meals
Taking medications
Getting to the doctor's office
Do they have difficulty remembering things such as paying their bills each month?
Yes
No
Have they ever beein diagnosed with dementia or Alzheimer's?
Yes
No
Do you have additional information to share? (Optional)
Submit
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