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: