Intake form

Name *

Email address *

What is the age of the individual seeking placement?

What type of senior community are you considering?

Please select at least one option.

Independent Living

Assisted Living

Memory Care

Skilled Nursing

Continuing Care Retirement Community (CCRC)

Respite Care

What is your budget for senior living?

What specific needs does the individual have?

Please select at least one option.

Mobility Assistance

Medication Management

Memory Care

Meal Preparation

Social Activities

Transportation Services

What is your preferred location for the senior community?

Are there any specific amenities you are looking for?

Please select at least one option.

Private Room

Shared Room

Outdoor Space

Fitness Center

Pet-Friendly

Transportation Services

What is the expected timeline for moving into a senior community?

Do you have any additional comments or requirements?

Additional questions or comments

Living Solutions Care