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Elder Care Referral Service.
Elder Care Assessment and Placement
Assistance Tailored to Your Family's Needs.

 Elder Care for Southern California
San Diego County, Orange County
Inland Empire

 

Questionnaire

Please complete the following so that we may better assist you:

(Press TAB to move to the next text box)

 

  *Required fields
*Your Name
Address
City
State
Zip
*Your phone
*Your email
  Name of Potential Resident (if different from above)
Potential Resident
Relationship

What is the age of the potential resident?:  

Ambulatory Status
Unassisted  Cane  Walker  Wheel Chair

Health Status
Continent  Incontinent 

Diabetes?
No  Yes  Pills  Insulin  Special Diet

Mental Status
Alert  Short-term memory loss  Alzheimer's  Wanders

I only want to consider facilities within:
No limit  5 miles  10 miles  15 miles

What is your desired price range?  Price information
(Check all that apply)
SSI- $999 $1000 - $1999  $2000 - $2999  $3000 - $3999+


What type of room are you looking for? (Check all that apply)
Private room  Female Semi-private  Male Semi-private


What size of facility would the resident prefer? More information
Any size  6 residents or less  50 residents or less
More than 50 residents


Does the resident plan on bringing a pet?
None  Cat  Dog  Other


When is the resident expect to move in?
ASAP  1 - 2 weeks  2 - 4 weeks  Not sure


What areas would you like to consider? (Check all that apply.)
  San Diego County: North County  Central  East County  South Bay
  Orange County: Santa Ana Area  Beaches  South OC  Brea and North OC
  San Bernardino County: Inland Empire  High Desert  Palm Springs Area  San Bernardino
  Riverside County: North  South  East  Riverside


Please provide other relevant facts: Examples


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