Paginated Questionnaire Step 1 of 8 12% Please answer a few important questions to receive your personalized senior care options, completely free of charge.What is your relationship to the person in need of senior care?(Required)Daughter of fatherDaughter of motherSon of fatherSon of motherSiblingSpouseMyselfMyself and spouseOther relativeFriendWhat is your loved one's name(Required) First Last (We'll need the first and last name to match with a community)What is your loved one's age?(Required)Please enter a number from 55 to 130.(must be 55 or older, per community requirements) How quickly do you need to find care?(Required)ImmediatelyWithin 30 daysWithin 60 daysNo rushWhat is your preferred location?(Required)(can be city or zipcode)What is the maximum distance you're willing to travel to your preferred location?Under 10 miles15 miles20 miles25 miles30 miles50 miles and over(Consider the type of area - ex.,urban, suburban, rural - you live when deciding travel time) Where is your loved one living now?(Required)Home (lives alone)Home (with Spouse)Home (with Partner)Home (with professional caretaker)With familyRetirement CommunityResidential Care HomeAssisted LivingSkilled NursingRehab FacilityHospitalHow is your loved one's mobility?(Required)Good (can get around independently)Can walk with help (cane)Can walk with help (walker)WheelchairImmobile (temporary due to injury)Bedridden (unable to bear weight)(understanding mobility can help us find the right type of community)What is the name of the facility your loved one is currently living in?(Required)(understanding the current facility will help us better match your needs)Do they need assistance with any of the following? (Check all that apply)(Required) Medication Management Bathing Dressing Grooming Toileting Transferring Housekeeping Laundry Social Activities (Understanding lifestyle needs helps us match you to the right community) What type of medication assistance is needed?(Required)Can take medication on their ownNeeds help taking medication Is your loved one currently experiencing memory loss?(Required)YesNoI don't knowHave they experienced any of these behaviors? (Check all that apply)(Required) Wandering Aggressiveness Hallucinations Withdrawal Sundowning Judgment loss Inappropriateness Exit-seeking None (Understanding current behaviors will help us find the right type of community)What are your room preferences within a community?(Required)StudioOne BedroomTwo BedroomsWhat is your privacy preference for the room?(Required)PrivateSharedWhat is the total cost of care you believe your loved on/your family can afford for senior living?(Required)Less than $2,000$2,000-$2,499$2,500-$2,999$3,000-$3,999$4,000-$4,999$5,000-$5,999$6,000-$6,999Over $7000(Senior living costs vary by location and services offered, encompassing accommodations, food, personal care, social/recreational activities, health services, transportation, and acute care. Our advisors are here to assist with budget optimization and any inquiries you may have.) Is your loved one a Veteran or the spouse of a wartime Veteran?(Required)YesNoI’m not sure(Qualified veterans - including spouses/widows/widowers - may be eligible for a Veterans Administration Aid and Attendance benefit)Is your loved one receiving Aid and Attendance Benefits from the Veterans Affairs Administration?(Required)YesNoNo, but we have started the application process(Most individuals who have not moved to a senior community may not be a recipient yet. If you are unsure, please select, 'No')How do you plan to pay for care? (Check all that apply)(Required) Personal savings Family support Stock, Bonds, CDs, or IRAs Long-term care insurance 401ks Monthly income Home to sell Other assets VA Benefits Medicaid Thank you! We have identified several community options that best match the information you provided!What is the best way for us to share your personalized results with you?(Required)Phone callText messageThere are no costs for your personalized results Ready for your personalized options? We just need three final pieces of information to share your results.Name(Required) First Last Email(Required) Phone(Required) By clicking "Review my options," you acknowledge our Terms of Use and Privacy Policy and agree to receive texts, emails, and calls from our Senior Living Care Advisors. Your consent does not obligate you to use our service.Please review your information below and click "Previous" if you need to change anything, or "Review my options" if accurate.{all_fields}CAPTCHANameThis field is for validation purposes and should be left unchanged.
