*Name of Contact Person :   *Last:

 

*Address *City *State *Zip

 

*Phone (area code) Cellular

 

Fax No:               *EMail  

 

*Clients Name:         Your relation to Client?

 

* Today's Date:

 

Please contact me as soon as possible regarding this matter.

This information is for a family member or friend.

This information is for me.

Select any of the following options you are inquiring about: Please select all that apply

Assisted Living
Board and Care
Independent Living
In-Home Care

Retirement Living

Hospice

Retirement Living

Skilled Nursing

Mentally Disabled      Age 18-59     Over 60

Adult Day Care

Respite

*I am looking for care closest to the following areas or Zip Codes:

*What is your approximate monthly budget to  pay 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

 

Who does this budget cover?

 

Myself Both of us Parents Individually

 

*What is the primary diagnosis of this person?

Does this person have any of the following medical issues?

ELIMINATION

Incontinent  Bowl  Bladder only

 

AMBULATORY

Ambulatory  Non Ambulatory  Cane or Walker  Wheelchair  Elect Wheelchair  Fall Risk Bed Bound

 

DIABETIC

Diabetic Oral Meds Self Inject Needs Shot givenSelf Accu CkSliding Scale

 

PSYCH

Alert  Confused  Mild Dementia  Mod Dem   Adv Dem  Depression   Bi Polar

Mild Alzheimer  Mod ALZ  Adv ALZ  Wanders off    Combative  

 

ADDITIONAL ISSUES

Oxygen   Dialysis   Seizures  Awake PM  Smoker Stroke Heart Disease  CPOD   Cancer

Hospice  

 

BODY

Physical Therapy   Fractured Hip   High Blood pressure   Failure to Thrive  Arthritis

 

What Daily Assistance do you need?

 

Medication Management     Dressing   Choose one Minimum Moderate Maximum      Bathing/Showering  Choose One Minimum Moderate Maximum  

 

Toilet/Hygiene Choose One Minimum Moderate Maximum

 

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Are you looking for more information in these areas?

Wheelchair or Scooter           Movers          Transportation to appointments           Real Estate Broker

Durable Power of Attorney forms               Conservator information           Attorney       

Insurance      Long Term Insurance    Health Insurance (HMO or Medigap) 

Home Maintenance (cleaning services)

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I understand that a care consultant will contact me regarding the above information. Lifetime Solutions is a free placement service and will not solicit any products you are not requesting.

I am requesting a care consultant contact me.

The best time for contact is:

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What kind of comment would you like to send?

 If you have been help by our company you may 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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