Following your completion of this form, a counselor will compile a personalized list of appropriate options to assist you in your search for senior care communities. The accuracy of our information is based on the completeness of your information. This list can be mailed, e-mailed, or faxed directly to you.

 

Important Information for you to know BEFORE you start

 

This form is designed to assist individuals in finding appropriate senior care communities when there is an immediate need (within 6 months). Once we have this information we will go through our database of over 2500 communities and compile a list of appropriate facilities (usually between 6-19). Often an individual can usually be placed in a community in less than a week once once their physician and the administrator of the community have evaluated them.

When we provide you with the information regarding these communities, we are also providing them your contact information so they can contact you to arrange for a tour of their community.

Our service to you is free. We are not supported through any government or non-government funding. In order to provide this service, like all senior care referral agencies within the state, we have entered into a contract with the communities. They pay us a marketing fee if an individual we first referred moves into their community.

If you are just exploring for use at a time greater than 6 months, please do not use this form but call our toll free number 800-777-7575 to speak to one of our counselors.
 

Your Contact Information (* indicates required fields)

 

*SalutationMrMs
*First Name:
*Last Name:
*Address
*City
State
*Zip Code

*Daytime Tel Number w/Area Code
Extension
Hours

Evening Tel Number w/Area Code
Extension
Hours

 

Fax Number w/Area Code
*Email Address
Client's Information
*First Name:
*Last Name:
*GenderMaleFemale
*Age
*Client currently resides
Currently in facility? What is the total cost? If in a CA facility, please give us the name so we don't notify the facility of your interest in moving.
What prompted this housing search?
*You are their
Care Needs

Do they need assistance with the following:  (please check all that apply)

 Bathing

 Dressing

 Remembering their medication

 Using the restroom

 

Are there bladder incontinency issues?Yes No

Are there bowel incontinency issues?Yes No

Do they have the following diagnosis:  

 Parkinson's

 Emphysema

 Severe Arthritis

 

Are they:

 Blind

 Hard of Hearing

 Diabetic

 Treated by diet or pills
 Insulin Injection - self
 Insulin Injection - by someone else

 

Mental Information:

Are they alert?  Yes   No - if No, then what form of dementia behaviors are exhibited?

  Short term memory loss

  Alzheimer's - Doctor Diagnosed only

  Combative or striking out

  Up most nights needing care

  Wandering away and getting lost (leaving at inappropriate times)

 

Mobility:

Can they walk unassisted?  Yes   No - then what kind of assisted is required?

  Use a cane
  Use a walker
  Wheelchair bound
  Need help transferring from wheelchair to bed
  Require assistance turning over in bed to prevent bedsores

 

Funding

Medicare and Medi-Cal do not pay for assisted living costs. SSI rooms are very limited.

 

* TOTAL Maximum funds available per month for senior housing between client & family:

 

* Are you looking for a shared or private room? (SSI offers shared rooms only)

Information Desired

  Residential Care Homes

Majority Private Pay; SSI in limited cases

  Assisted Living Facilities

Majority Private Pay; VA; SSI in limited cases

  Alzheimer's/Dementia Care

ALL Private Pay

  In Home Companion Care (Orange, Los Angeles, San Bernardino and Riverside Counties)

Private Pay

 

Geographical Preferences:

 

*1st City Desired:    2nd City Desired: 

 

 If you have family living in different areas that might be another option to search for care homes, please fill out below:
2nd Choice: 1st City Desired:  2nd City Desired: 
3rd Choice:  1st City Desired:  2nd City Desired: 

 

What is the furthest distance you wish to travel? miles
 * How soon before the move takes place?
 

 * Have you contacted any other referral agencies? Yes No
 * Have you seen any homes so far?Yes No
     If yes, which ones (so we don't duplicate your efforts)

Any other information you'd like to let us know:

 

* Yes, I understand that this information will be provided to the facilities referred so they may contact me. Also, I understand that even though this is a free service to me, California Registry charges the facility a marketing fee when a placement has been arranged.