Senior Transitions - Helping Seniors Find Retirement Living Suited To Their Individual Needs

Senior Community retirement living seniors and assisted living centers

senior living community alzheimer independent assisted

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Senior Transitions - Connecting Seniors With Senior Living Communities

Find Assisted Living Information By Specific State

Senior Transitions values your privacy and that of your loved one(s). The information that you send to us via this assessment form will be treated as strictly confidential by our company and by the senior assisted or independent living communities that we contact on your behalf.

Fill out the following form to have your information sent directly to one of our placement specialists. They will then contact you concerning your request for assistance. Please be as complete as possible. This will enable our specialists to best match your needs to senior living communities. Items in red are required.

Your Contact Information

Your Full Name:

Primary Phone:

Secondary Phone:

Fax:

Email Address:

What is your relationship to the senior?:

Senior's Information

Senior's Name:

Sex:

F M

Age:

Date of Birth:

(mm/dd/yyyy)

Additional Person, if any:

Sex:

F M

Age:

Date of Birth:

(mm/dd/yyyy)

Current Residence:

Home With Relatives Community

If community, please indicate name:

Medical Diagnosis

Alzheimer's	Hypertension
Cancer	Kidney Disease
Dementia	Mental Illness
Depression	Parkinson's
Diabetes	Stroke
Emphysema	TIAs
Heart Disease
Congestive Heart Disease
Macular Degeneration
Other?

	Assistance Needed
	None	Some	Full
Walking
Bathing / Showering
Grooming
Eating
Catheter
Colostomy
Medicating
Toileting
Injections
Dressing
Incontinence

Mobility

No Assistance	Electric cart
Cane	Walker
Bedridden	Wheelchair

Memory

Like a Steel Trap	Forgetful
Confused	Wanderer

Additional Information

What type of Communities are you looking for:

Continuing Care Retirement Community
Independent Living
Assisted Living
Board & Care Home
Alzheimer's/Dementia
Skilled Nursing Facility
Locked Facility
Respite Care

Type of Room Desired?:

Studio
1 Bed
2 Bed
3 Bed
Shared

What is the monthly budget

Location - Choice 1

State Desired

City or Cities

Zip Code (if avail)

Location - Choice 2

State Desired

City or Cities

Zip Code (if avail)

Location - Choice 3

State Desired

City or Cities

Zip Code (if avail)

How soon do you need placement?

To expedite our service to you, please indicate any communities you have toured or contacted (to avoid duplication):

To expedite our service to you, please let us know what circumstances have led you to consider senior/assisted living?

Form v. 1/09

Definitions
	Assisted Living

	Independent Living

	Congregate Housing

	Continuing Care Retirement Community

	Nursing Home

	Residential Board and Care Home

	Alzheimer's

Senior Transitions is an independent referral service for senior assisted living, senior communities and independent senior living. Any senior living data provided on the Senior Transitions web site is for informational purposes only and is not intended to be used as a substitute for consultation with a qualified health care or geriatric professional. The Senior Transitions web site may contain advertisements and links to third party websites, and does not make any representation, warranty, or endorsement of any product or service or the content or accuracy of any materials contained in, or linked to, any advertisement or link on the Site.