Inquiry Form

Are you completeing this form on behalf of someone else? *YesNo

Please Provide YOUR Information BelowYou will be considered the point of contact, since you are completing this form on someone else's behalf.

First Name *

Last Name *

Relationship to Potential Resident *

Phone Number *

Email Address *

Preferred Method of Contact *EmailPhone

Information of Potential Resident

First Name *

Last Name *

Age

Street Address *

Apartment, suite, etc

City *

State *

ZIP Code *

Phone Number *

Email Address

Preferred Method of ContactEmailPhone

Current Setting *At HomeIn A Facility

Name of Current Facility

Level of Care Being Sought *Independent LivingAssisted LivingSkilled Nursing Care

Level of Care Currently Being Provided *Independent LivingAssisted LivingSkilled Nursing CareNone

If currently receiving assistance, what daily activities (ADLs) are being supported? (Check all that apply)BathingDressingGroomingEatingTransferring In/Out of BedOther

OTHER (Please Describe):

Mobility: Is the individual able to move around Independently? *YesNo

Please explain (e.g., uses walker independently, self-propels wheelchair, etc.):

Has the individual been diagnosed with dementia or any memory-related condition (e.g., Alzheimer’s)? *Please note: We’re NOT licensed for memory care, we can only accommodate mild cognitive impairment following a health assessment.YesNoNot Sure

Please explain:

What major medical diagnoses should we be aware of? *

Financial Status *Private PayFinancial Assistance

Please Specify Financial Assistance *Medi-CalAssisted Living WaiverOther

OTHER, please specify:

Submit

Please do not fill in this field.