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Senior Care Solutions is here to provide you with answers, to help ease your burden, and to assist you in finding appropriate solutions, at no cost to you or your loved ones.

Complete this form, including as much information as possible, so we may assist you to the best of our ability.

THE SENIOR CARE SOLUTIONS CARE FINDING FORM
PLEASE COMPLETE ALL FIELDS BEFORE YOU SUBMIT THIS FORM
This senior person will need help with the following:
Ambulation - if yes, using:	a walker wheelchair
Transferring - is yes:	Can they assist? Yes
Meal Preparation
Medication Assistance
Taking Showers or Baths
Dressing Themselves
Incontinence - if yes, is it:	bladder bowel
Do they wear depends:	yes no not sure

The current health condition of this senior person:
Does this person experience a loss of memory?
If so, have they had any problems with wandering?	yes no not sure

The health condition of this person includes:
Arthritis	Alzheimer's / Dementia
Diabetes	Parkinson's Disease
Heart Disease	Osteoporosis
Macular Degeneration	Cancer
Anxiety	Depression
please choose all that are applicable

What is the monthly budget available to cover this care:
Minimum Budget:	Maximum Budget:


Information about the senior person this search is for:
Please answer these introductory questions about the person you are doing the search for to help us get better acquainted with them.
The name of the senior is:
This person is related to me as:
The age of this senior is:
This senior is now living in a:
I desire a care facility within:
The type of senior care desired:

I would like to find care for this person in or near the area of:
City:	State:

Additional Information:
Please tell us what is prompting your search for care and any additional information about you or your loved one that will help in finding the most appropriate match:

Please remember to also provide us with your information

If you do not type in your name, phone number, and e-mail address it will be very difficult for us to assist you. All information is kept confidential
* Your First and Last Name:	*
Your Mailing Address:
City:
State:
Zip:
* Home Phone :	*
Work Phone:
* Email:	*





How did you hear about us :
Yes, please send me brochures from the properties that match my requested criteria as listed above.

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