Assisted Living 101

Discovery Questionnaire


 
Name *:
Email Address *:
Home Phone *: () -
Cell Phone: () -
Address *:
How did you hear about us?
To the best of my knowledge the needs that my loved one has include the following, (please check all that apply):
Meals Laundry Housekeeping
Transportation Socialization Medications
Showers Ambulation Incontinence
Escorts Redirecting Wandering
Behavioral Psych Diagnosis
Other Needs:
How soon are you looking to relocate?
What areas are you looking for?
Are you private pay? Yes No
Do you have a long term care policy?
Yes No
Are you applying for ALTCS? Yes No
Would you like to learn more about the ALTCS program? Yes No
Please tell us about any recent hospital visits that you feel would be relevant to the assisted care you are seeking:
 
I understand that Assisted Living - 101 will forward my information to those facilities that it best determines will suit the needs based on information provided in the “discovery” questionnaire. I understand that I will NOT be charged a fee for Assisted Living - 101 to forward my information to facilities.
 

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