Assess Your Needs – Senior Care Alliance

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Assess Your Needs

Assess Your Needs

Assess Your Needs

Fill out the form below so our team can help find the best care options.

Your Contact Information

Last Name *

First Name *

Phone *

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:

Gender:

Male
Female

Age:

Height:

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

Budget

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

Please select your maximum monthly budget:

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

Select all that apply:

Needs assistive device to get around (walker, wheelchair)
Diagnosed with Dementia or Alzheimer's Disease
Takes medications for mental health issues (Bi-Polar, Schizophrenia, Depression)
Has severe vision impairment or is blind
Can't control when they urinate
Uses a feeding tube
Has a urinary catheter
Needs oxygen therapy or uses a device to get oxygen
Has a tracheotomy tube
Bedridden or bed bound
Insists on bringing a small pet
Uses an electric scooter
At risk of wandering or exiting without the needed supervision
Needs help from a licensed professional to administer injections
Has severe hearing impairment or is deaf
Can't control when they have a bowel movement
Has a colostomy or pouch to collect waste from the body
Smoker
Has a bandaged wound someone else needs to take care of
Overweight or obese

Additional Information

Is there anything else you would like us to know?

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Comment

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(949) 241-7294
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