DEFINE CARE NEEDS

Needs Assessments

Complete this form to assist us in helping you locate the appropriate facility in your elderly family member's city or nearby area.  Complete only the items that apply to your family member.  All personal information you provide is held in strictest confidence by our company and is not shared with advertisers or any other parties.

*=Required Field

*Senior is located near
 

*City:

*State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Dakota Tennessee Texas Utah Vermont Virginia Washington State Washington DC Wisconsin Wyoming

Zip:

Senior's Name:

*First:

Last:

Height:Weight:

*Age:

PHYSICAL INFORMATION

Ambulation Level   (check all that apply)

Walks unassisted

Cane

Walker

Wheelchair

Wheelchair Transfer Assistance:

Needs no help

Needs some help

Needs total assistance

Need Help With Activities Of Daily Living   (check all that apply)

Bathing

Dressing

Hair care, shaving, or dental

Eating

Toileting

Incontinent   (check all that apply)

Bladder

Bowel

Wears diapers

Senses   (check all that apply)

Fair to good vision

Legally blind

Fair to good hearing

Deaf

Night Time   (check all that apply)

Sleeps through the night

Needs help with toileting

Up three or more times

MEDICAL INFORMATION

Cognitive Impairment  (check all that apply)

Diagnosed with Alzheimer's

Diagnosed with dementia

Confused

Short term memory loss

Wanders at night

Wanders outside

Agitated or combative

Special Medical Needs   (check all that apply)

Oxygen

Urinary catheter

Colostomy

Diabetic   (check all that apply)

Controlled with medications

Insulin injections

Special diet

Additional Information Regarding Your Loved One
(do not exceed 2000 characters)

RESPONSIBLE  PARTY  INFORMATION (*=required field)

*First Name:

*Last Name:

*Address 1:

*Address 2:

*City:

*State:

*Zip code:

*Relationship to Senior

*Home phone #

*Other phone #

*E-mail address:

*Facility Type:

Assisted living

Small board and care homes

Alzheimer's secured residence

Retirement community

*Apartment/Room Type:

1 Bedroom

2 Bedrooms

Studio

Private room

Semi-private room

Estimated move-in date:

*Monthly Budget range:

Minimum

select under $1,000 $1,500 $2,000 $3,000 $4,000 over $4,000  

Maximum

select under $1,000 $1,500 $2,000 $3,000 $4,000 over $4,000  

Additional Information Regarding Your Search
(do not exceed 2000 characters)

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About Elder Care
(division of Elder Care Referral Services, Inc.)
3800 Auburn Blvd., Suite C
Sacramento, California 95821
Telephone: (916) 489-8779
Auburn: (530) 889-0303
Placerville (530) 626-5900
Fax: (916) 489-0191
E-Mail: info@eldercareservices.com
URL: www.eldercareservices.com

Copyright 97,98,99,00,01,2002 Elder Care Referral Services, Inc., All rights reserved