Information Request Form

Inquirer:

Recipient:

Select from the list below, which best describes your primary need.

In-Home Care   Adult Day Care     Assisted Living Facility  Group Home/Residential Care Home   Skilled Nursing Home
Independent Living-Senior Community Personal Care Attendant for vacations           Respite            Hospice

Mentally Disabled Age 1-18    Age 18-59    Age Over 60
What is approximate monthly budget to pay for care? Check all that apply     Select $75-$600 $900-$1400 $1400-$1800 $1800-$2500 $2500-$3500 $3500-$6000   

Select Funding Source/Select those that apply:
Private Pay  Family Supplements  Long Term Ins.  Pension SSI Only  Medicaid/Public Assistance 
Disability     Workers Comp   Is Recipient a Veteran?   Select Yes No    (Recipient may qualify for veteran's assistance program)

What are some of the recipients health issues?

 Medical Health Conditions
Heart Disease  COPD  High Blood Pressure  Stroke  Seizures  Cancer  Dialysis  Oxygen  Hospice

Ambulation
Self Ambulatory Ambulatory with Assistance Non-Ambulatory Cane/Walker   Wheelchair   Fall Risk  Bed Bound

Diabetes
Diabetic   Oral Meds  Insulin dependant  Self Injects

Elimination
Continent  Incontinent  Bowel  Bladder only Catheter  Colostomy Bag    Full Briefs/Pull Ups Pads

Mental Status
Alert Confused Dementia Alzheimer's Depression Bi-Polar Combative Wanders Off   Awake PM

BODY
Physical Therapy  Fractured Hip/Leg  Occupational Therapy  Arthritis  Scoliosis Paralyzed

Other conditions or information not listed above:

Send company literature                   
I would like to have an assessment.