Find Assisted Living Communities for Free
Complete this short assessment to let your loved ones enjoy their twilight years.
Back
Next
Full Name
*
First Name
Last Name
E-mail
Phone Number
*
Back
Next
Please tell us who you're completing this assessment for?
*
Parent
Spouse
Friend
Family Member
Self
Back
Next
What is their age?
Under 55
55-64
65-74
75-84
85+
Please tell us about the primary means of payment for their senior living options.
Private payment by resident/senior
Medicaid/state payment
Long-term care insurance
Veterans benefits
Not sure
Back
Next
What city does the senior currently live in?
*
What city/town would the senior like to live in?
*
Back
Next
How soon will you be needing to make a decision about senior living options?
*
Within the week
Within the next 30 days
Within 30-60 days
Within 60-90 days
Not sure
Back
Next
Please indicate any health conditions you are aware of for this person.
Arthritis
Cancer - Active Treatment
Cancer - Survivor
Stroke
Open Wounds
Forgetfulness
Dementia
Alzheimer's
Diabetes
Chronic hip, knee, back pain
Don't know
None of the Above
Back
Next
Please indicate if the person has been in the hospital, rehabilitation center or nursing home in the last three (3) months.
Yes
No
Don't Know
Hospital
Rehabilitation Center
Nursing Home
Back
Next
Does this person take medication on a daily basis? If so, how many?
N/A
1-2 medications daily
3-5 medications daily
6+ medications daily
Unsure
Back
Next
Has this person fallen in the last three (3) months?
Yes
No
Don't Know
Back
Next
Please rate the importance of the following activities for this person:
Very Important
Somewhat Important
Not Important
Attending religious service/church
Participating in social clubs/activities
Participating in physical activities/exercise
Going out to eat
Going out to shop
Driving
Phone Number
-
Area Code
Phone Number
Submit
(c) 2015 Concierge Care Advisors, LLC
Should be Empty: