Assess Your Needs

Make the right decision for your loved one. With so many care options out there, it’s not an easy task. We’re here to help! Take a few minutes to answer some questions and a local senior care advisor will contact you and walk you through the process, or simply give us a call at (408) 610-9997.

Assessment

Contact Information

First Name

Last Name

Phone Number

Email Address

Preferences

Location of Care

Enter Area, City(s) or Zip Code(s)

Decision Timeframe Immediately 1-2 Weeks 2-4 Weeks Within 3 Months Within 1 Year

Senior is Currently at: Hospital Rehab Facility Home Alone Home with a Spouse/Caregiver Family Member/Friend's Home Senior Community Other

Seeking Care at: Retirement or Independent Living Community Assisted Living Community In-Home Care Skilled Nursing Facility Not Sure

How many seniors are you seeking care for:

1

2

I’m inquiring for my: Spouse Mother/Father Daughter/Son Sibling/Family Patient/Client Friend/Other

Senior in need of care:

Name

Gender

Male

Female

Age

Approximate Weight

Is the senior or their spouse a Veteran?

Yes

No

Not Sure

Level of care needs: Independent Needs Some Weekly Assistance Needs Some Daily Assistance Needs Considerable Daily Assistance Completely Dependent End-of-Life or Hospice Care

Do they require injections?

Yes

No

Not Sure

In order to get the care they need, this person: Is willing to move out of their home and into a facility Prefers not to move out of their home and into a facility Is not willing to move out of their home Has no preference about where they receive care

What are the biggest challenges you will face in making the transition?

Paying for adequate care

Convincing my loved one that a change is required

Getting all family members in agreement on what to do

Finding the right facility that meets my loved one's unique needs

Other

Budget

MAXIMUM Per Person monthly budget? $5,000+ Up to $5,000 Up to $4,500 Up to $4,000 Up to $3,500 Up to $3,000 Up to $2,500 Up to $2,000 Up to $1,500

(This will not exclude lower cost options as long as they can provide adequate care for your loved one’s needs)

MINIMUM class of community you are looking for? High-End Upper Moderate Moderate Lower-End

Funding source(s) you plan to use to cover the costs?

Private funds (income or savings)

Long-term care insurance

TRICARE (military)

Medicare/Medi-Cal

Supplemental Security Income (SSI)

Activities of Daily Living

Activity

Bathing

Accomplishes Alone

Needs Some Help

Needs Much Help

Getting Dressed

Accomplishes Alone

Needs Some Help

Needs Much Help

Feeding Self

Accomplishes Alone

Needs Some Help

Needs Much Help

Eating a Nutritious Diet

Accomplishes Alone

Needs Some Help

Needs Much Help

Walking

Accomplishes Alone

Needs Some Help

Needs Much Help

Using the Toilet

Accomplishes Alone

Needs Some Help

Needs Much Help

Getting out of Bed/Chair

Accomplishes Alone

Needs Some Help

Needs Much Help

Taking Medications

Accomplishes Alone

Needs Some Help

Needs Much Help

Competency

Health

Good

Moderate

Poor

Mobility

Good

Moderate

Poor

Balance

Good

Moderate

Poor

Memory

Good

Moderate

Poor

Managing Daily Activities

Good

Moderate

Poor

Managing Medications

Good

Moderate

Poor

Decision Making

Good

Moderate

Poor

Managing Finances

Good

Moderate

Poor

Unique Care Selections

Unique Care

Has a bandaged wound someone else needs to take care of.

Needs an assistive device to get around (walker, wheelchair).

Uses an electric scooter.

Has been diagnosed with Dementia or Alzheimer’s Disease.

At risk of wandering or exiting without the needed supervision.

Takes medications for mental health issues (Bi-Polar, Schizophrenia, Depression).

Needs help from a licensed professional to administer injections.

Has severe vision impairment or is blind.

Has severe hearing impairment or is deaf.

Cannot control when they urinate.

Cannot control when they have a bowel movement.

Uses a feeding tube.

Has a colostomy or pouch to collect waste from the body.

Has a urinary catheter.

Is a smoker.

Needs oxygen therapy or uses a device to get oxygen.

Needs a ventilator.

Has a tracheotomy tube.

Has a bandaged wound someone else needs to take care of.

Bedridden or bed bound.

Is overweight or obese.

Insists on bringing a small pet.

Please check all that apply

Any additional information you’d like us to know?

If you are human, leave this field blank.