Senior Care Assessment

Hi,

You can call or email me directly at any time for assistance. Or if you prefer, please fill out the form below and I’ll have many of the details I need to assist your family even before we speak.

Thank you,

Lise

 

Personal Information:

Family Member Inquiring

Senior Needing Care

Home Phone

Mobile Phone

Name of Senior

Age

Height

Weight

Current Location

Care Required:

Cognitive Abilities (MCI, dementia, Alzheimer’s)

If Yes, Wandering or Behaviors

Ambulation (Walker, Wheelchair, Escort Needed)

Incontinence (Bladder and/or Bowel)

Hygiene (Shower Assist or Stand By)

Dressing (Complete or Assist)

Hospice (if Yes, When Prescribed)

Transfer (Weight Bearing, One Person or Two Persons)

Other Care (Injections, Colostomy, Etc)

Location:

Optimum Cities/Zip Codes For Placement

Budget:

Monthly Income

Assets or Savings

Medi-Cal

Other (House to Sell, Veteran or Surviving Spouse of Veteran)

Legal:

DPOA (With Contact Info if Not Above)

Fiduciary/Other Responsible Party

Additional Comments: