With the following information, a counselor can begin to compile your personalized list of appropriate options to assist you in your search. This list can be mailed, e-mailed, or faxed directly to you. The more thorough and complete the information, the easier it will be to send you the most appropriate options.

Your Contact Information (* indicates required fields)

 

*Your Name:Please add Mr. or Ms.
*Address
City
State
Zip Code

*Daytime Tel Number w/Area Code
Extension
Hours

Evening Tel Number w/Area Code
Extension
Hours

 

Fax Number w/Area Code
*Email Address
Client's Information
*Client's NamePlease add Mr. or Ms.
*Age
Client currently resides
Currently in faciliy? What is the total cost?
What prompted this housing search?
*You are their
Care Needs

Do they need assistance with the following:  (please check all that apply)

 Bathing

 Dressing

 Remembering their medication

 Using the restroom

 

Are there bladder incontinency issues?Yes No

Are there bowel incontinency issues?Yes No

Do they have the following diagnosis:  

 Parkinson's

 Emphysema

 Severe Arthritis

 

Are they:

 Blind

 Hard of Hearing

 Diabetic

 Treated by diet or pills
 Insulin Injection - self
 Insulin Injection - by someone else

 

Mental Information:

Are they alert?  Yes   No

  Short term memory loss

  Alzheimer's

  Combative

  Up at night needing care

  Wandering away and getting lost (leaving at inappropriate times)

 

Mobility:

Can they walk unassisted?  Yes   No

  Use a cane
  Use a walker
  Wheelchair bound
  Need help transferring from wheelchair to bed
  Require assistance turning over in bed to prevent bedsores

 

Funding

Medicare and Medi-Cal do not pay for assisted living costs. SSI rooms are very limited.

 

Does the client have:

  Medi-Cal
  SSI only

 

Other: (Do NOT include Government Funds)

Client Contribution:  per month
Family Contribution:  per month

 

* Are you looking for a shared or private room? (shared only if using SSI)

Information Desired

  Residential Care Homes

Majority Private Pay; SSI in limited cases

  Assisted Living Facilities

Majority Private Pay; VA; SSI in limited cases

  Alzheimer's/Dementia Care

ALL Private Pay

  Skilled Nursing

Medi-Cal; Private Pay

  In Home Companion Care (Orange, Los Angeles, San Bernardino and Riverside Counties)

Private Pay

 

Geographical Preferences:

 

* County Desired:   or  City Desired: 

 

 If you have family living in different areas that might be another option to search for care homes, please fill out below:
2nd Choice: County Desired: or City Desired: 
3rd Choice: County Desired:  or City Desired: