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.

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To 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:

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

 

* Choose below $900-1300 $1400-1800 $1800-2500 $2500-3500 $3500-6000  

SSI only	Medicaid/Public Assistance
Disability	Pension
Family Supplements

Whom does this budget cover?

 

Choose Below Myself Both of us Parents Individually

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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   Choose one Minimum Moderate Maximum      Bathing/Showering  Choose One Minimum Moderate Maximum     Toilet/Hygiene Choose One Minimum Moderate Maximum

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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

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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:

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 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

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