Senior Consultation Form

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Senior Consultation Form

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Please take a moment to fill out our consultation form
which will allow us to better serve you.

Senior Name*
Contact Name*
Relationship to Senior
Contact Phone Number*
Alterntative Phone Number
Contact E-mail Address*
Age of Senior*
City Senior Presently Resides*
State Senior Presently Resides*
Is Senior*
- Independently Mobile
- Walk with Cane
- Walk with Walker
- Wheel Chair
Where do they reside?*
- Private home or Apartment
- With Family
- In Senior Living Community
What are you interested in discussing*
- In Home Care Assistance
- Assisted Living Communities
- Memory Care Communities
- Private Adult Homes
- Comparing all your options
Please check the appropriate box to the questions listed below:
Are there memory issues?*
- Yes
- No
Have they been diagnosed with Alzeheimers, Dementia or Parkinson’s Disease?*
- Yes
- No
Are there wandering issues?*
- Yes
- No
Are there behavioral issues?*
- Yes
- No
Are they Diabetic?*
- Yes
- No
Do they require insulin injections?*
- Yes
- No
Do they need assistance transferring?*
- Yes
- No
Do they need assistance toiletting?*
- Yes
- No
Do they need assistance bathing?*
- Yes
- No
Do they need assistance with medication management?*
- Yes
- No
Do they need to be reminded to eat meals?*
- Yes
- No
Do they need assistance feeding themselves?*
- Yes
- No
Do they still drive?*
- Yes
- No
Do they have poor vision?*
- Yes
- No
Do they need assistance dressing?*
- Yes
- No
Have they been diagnosed with Arthritis or Osteoporosis?*
- Yes
- No
Do they have high blood pressure?*
- Yes
- No
Do they have low blood pressure?*
- Yes
- No
Do they have a heart condition?*
- Yes
- No

Why Choose Us

A Senior’s Choice provides the following services:

Help families evaluate issues such as care, lifestyle and finances.
Help our clients (families) find senior housing and care faster and easier.
By allowing us to do the leg work for you, we take the worry and pressure off the family, creating peace of mind.
Help find the perfect eldercare solution.