Assisted Living Questionnaire

1. First Name

2. Last Name

3. Phone Number

4. Email Address

5. Are you familiar with what the Assisted Living environment is?YesNoI would like more information.

6. Who are you seeking care for?ParentGrandparentSpouseSiblingOther

7. If you chose other, please elaborate:

8. Are you concerned about him/her living alone?YesNo

9. Does s/he need more care than they currently have?YesNo

10. Are you noticing a decline in cognitive or motor functions?YesSomewhatNot Really

11. Are you noticing a change in overall mood and motivation?YesSomewhatNot Really

12. Does s/he seem more sad, lonely, or disengaged in activities they once enjoyed? YesSomewhatNot Really

13. Have you noticed a change in his/her eating or sleeping patterns? YesSomewhatNot Really

14. I am seeking:Long-term Assisted Living CareMemory Care (Alzheimer's, Dementia, etc.)Short-term (or Respite Care) AssistanceOther

15. If you chose other, please elaborate:

16. Is there anything else you would like to tell us?

DISCLAIMER NOTICE. I understand that I am sending personally identifiable information through email.I Understand and Agree.