top of page
Home
About Us
Our Services
FAQ
Resources
Contact Us
Complete Assessment
Senior Placement Assessment Form
Responsible Party / Primary Contact:
Full Name
*
Relationship to Prospect
*
Phone Number
Email
*
Mailing
Power of Attorney (POA) Status
Yes
No
Preferred Method of Communication
Phone
Email
Text
Is it okay to contact you for follow-up?
Yes
No
Prospective Resident Information
Full Name
Date of Birth
Age
Gender
Phone Number (if applicable)
Email Address (if applicable)
Current Living Situation (e.g., home alone, with family, rehab facility, hospital, etc.)
Current Address :
Okay to Contact Directly?
Yes
No
Lifestyle & Preferences
Personality / Temperament (Brief description) :
Describe a Typical Day :
Primary Reason for Transitioning to Care :
Preferred Language:
Religious or Spiritual Affiliation (if any)
Veteran or Military Service?
Yes
No
Does the individual currently:
Smoke
Own a pet
Drive
Require parking for a personal vehicle
Preferred Room Type:
Private
Shared
Studio
One Bedroom
No preference
Other Preferences or Special Requests:
Clinical Profile & Care Needs
Is the individual currently on hospice care?
Yes
No
Has there been a **diagnosis of dementia** or memory impairment?
Yes
No
Level of cognitive awareness:
Fully Cognitively Intact
Mild Impairment
Moderate
Severe
Behavioral Considerations:
Exit Seeking
Wandering
Aggression
Sundowning Behavior
Diagnosed Mental Health Conditions:
Physical Health Conditions:
Diabetes
Wound Care
Incontinence Care
Fall Risk
Mobility Issues
Other:
Physical Health Conditions:
Diabetes
Wound Care
Incontinence Care
Fall Risk
Mobility Issues
Other
Special Diet Requirements:
Diabetic
Low Sodium
Pureed
Mechanical Soft
Thickened Liquids
Other
Medication Management Needed?
Yes
No
Durable Medical Equipment in Use:
Walker
Wheelchair
Oxygen
Hoyer Lift
Hospital Bed
Other
Medical Contacts
Primary Care Physician:
Name
Phone Number:
Address/Facility:
Additional Providers (Specialists, Home Health, etc.):
Name :
Specialty:
Contact Information:
Do you have long term care insurance?
*
Additional Notes:
Submit
bottom of page
