Assess Your Needs – Senior Care Alliance

Your Contact Information

First Name

Last Name

Phone Number

Email Address

Your Preferences

Where are you seeking care?

The senior in need of care is currently at:

How quickly do you need to make a decision?

I'm seeking care at a:

About Your Loved One

I'm inquiring for my:

Name:

Age:

Gender:

Male Female

Approx. Weight:

Is the senior or their spouse a veteran?

Do they require injections?

Which best describes their level of care needs?

In order to get the care they need, this person

What are the biggest challenges you will face in making the transition? (choose all that apply)

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

Something else

Budget

Based on your budget, what's the minimum class of community you are looking for?

Please select your maximum monthly budget:

This will not stop us from finding lower cost options as long as they can provide adequate care for your loved one's needs.

What funding source(s) do you plan to use to cover the senior living cost? (choose all that apply)

Private funds (income or savings)

Long-term care insurance

TRICARE (military)

Medicare/Medi-Cal

Supplemental Security Income (SSI)

Activities of Daily Living

Please assess your loved one's activities below.

Activities

Bathing

Feeding self

Walking

Getting out of bed or a chair

Getting dressed

Eating a nutritious diet

Using the toilet

Taking medications

Competency

Health

Balance

Managing daily activities

Decision making

Mobility

Memory

Managing medications

Managing finances

Unique Care

Additional Information

Is there anything else you would like us to know?

CARE ASSESSMENT