Assessment

ASSESSMENT
*required fields

I am looking in Nevada for a place to live      I am looking in California for a place to live  

*Contact Person :   *Last:

 

*Address *City *State *Zip

 

*Phone (area code) Cellular

 

Fax No:                *E-Mail  

 

*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.


imageTo assist you more adequately select any of the following preferences .

Please select 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)

Assisted Living Board and Care or Group Home
Independent Living In-Home Care
Retirement Living Hospice
Skilled Nursing Mentally Disabled     
Age 18-59     Over 60
Adult Day Care Respite


*Please find me homes in the following Cities or Zip Codes:


*How will you pay for the for your care? Check all that apply.

 

* 

SSI only Medicaid/Public Assistance
Disability    Pension
Family Supplements  

Whom does this budget cover?

 


What are the medical issues for this individual?

Is this person:
Ambulatory  Non Ambulatory  Cane or Walker  Wheelchair  Elect Wheelchair  Fall Risk Bed Bound
Is this person:
Incontinent  Bowl  Bladder only
Is this person:
Diabetic Oral Meds Self Inject Needs Shot given Self Accu Ck Sliding Scale

Is this person:
Alert  Confused  Mild Dementia  Mod Dem   Adv Dem  Depression   Bi Polar

Mild Alzheimer  Mod ALZ  Adv ALZ  Wanders off    Combative  

Does this person have or need:
Oxygen   Dialysis   Seizures  Awake PM  Smoker Stroke Heart Disease  COPD   Cancer

Hospice   Physical Therapy   Fractured Hip   High Blood pressure   Failure to Thrive  Arthritis Medication Management

Does this person have or need:
Dressing        Bathing/Showering   

 

Toilet/Hygiene


Can we assist you with any of the additional needs or referrals?

Wheelchair or Scooter  Transportation to appointments      
Movers    Real Estate Broker
Durable Power of Attorney forms    Long Term Insurance 
Conservator information Elder Law Attorney       
Insurance Health Insurance (HMO or Medigap) 
Home Maintenance (carpet cleaning services) Reverse Mortgage

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 assessment is:


 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.

Complaint Problem Suggestion Praise

Enter your comments in the space provided below:

*Security Code:
security image

A Place for DadEveryones needs are different so we would like to assist you in your search for the proper home that can meet the requirements and budget you have. Please complete all areas that apply. Fill out a form for each person needing placement or help. We will respect your privacy and not release your medical information to any third party or advertisers.

________________________________________________________