FOR IMMEDIATE ASSISTANCE CALL US TOLL-FREE AT  1-888-489-8779 

 

 

E-Mail:
info@eldercareservices.com

1911 Douglas Blvd.,
Suite 85-198
Roseville, CA 95661
(Suburb of Sacramento)

Toll Free:
 1-888-489-8779
Local:
 (916) 783-8779
FAX:
 (916) 791-5396




Define Needs

Independent Living Information Form

Complete this form to assist us in helping you locate the appropriate independent living 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

I. Personal
*First Name: *Last Name *Age:

*Responsible Party: 		*Relationship:

*Address:

*Telephone:

*Email:


*City:

*State:

*Zip:

*Est. Start Looking Date:
*Est. Moving Date:

II. Medical Information (check all that apply)

Walks unassisted:
Cane:
Walker:
Wheelchair:
Alzheimer's:
Oxygen:
Diabetic:
Special diet:

III. Current Residence (check all that apply)

Own Home:
Apt:
Mobile Home:
Other:

IV. Financial (Budget)

Price Range Minimum

 

Price Range Maximum

 

Must Sell Home First:

V. Apartment/Room Type:

Studio

1 Bedroom

2 bedrooms

#meals

Hskp

 
Want Asst. Living
Pet
Laundry
Other
Area Desired:  
Comments:  

 

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