* Contact Person :
*Phone (area code)
*Clients Name that will be placed:
Your relation to Client?
I would like a person to contact me as soon as possible
regarding this matter.
This inquiry is for a family member or friend.
This inquiry is for me.
assist you more adequately select any of the following preferences .
all that apply to the person or individual who needs assistants.
*What is the primary diagnosis of this individual?
What type of
accommodations are you looking for? (select all that apply)
find me homes in the following Cities or Zip Codes:
will you pay for the for your care? Check all that apply.
Whom does this budget cover?
Both of us
What are the medical issues for this
Can we assist you with any of the additional needs or
I agree to have a staff member of LTC-Continuum
contact me regarding the above information. LTC-Continuum will not
solicit any products you are not requesting.
I agree to LTC-Continuum contacting
me. Please check here.
The best time for us to call and arrange an
If you have been helped by LTC-continuum would you
provide us with a referral letter under the comments section. We do
appreciate all referrals and recommendations.
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