Senior Choice

Placement Questionnaire for Couple

Please answer these questions to the best of your knowledge. The answers will help me find the best senior living options for you in the Ventura County area for us to tour.

Your Name * Required

Birthday * Required

Primary Phone Number

Primary Email

Partner's First & Last Name * Required

Partner's Birthday * Required

What's your current living situation?

i.e independent living, own home, with family, etc.

What type of senior living are you interested in? * Required

You may select more than one.

Independent Living

Assisted Living

Board & Care

Memory Care

Skilled Nursing

Home Care

What's your desired location? * Required

What's your budget? * Required

Tour Availability: List dates and times.

Note: this can be discussed during our next phone call.

Who is your primary care physician? * Required

Share your primary care physician's phone number * Required

Do you or your partner take any medications? If so, list them here. * Required

Health Status: Describe any health condition(s) you or your partner have. * Required

Is there anything else important to you that I should consider?

i.e pets, smoking, private or shared room, etc.

Share more information you think would help me understand you, your partner, and your situation better.

How did you hear about us? * Required

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