Senior Choice

Placement Questionnaire

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.

Name * Required

Birthday * Required

Phone number * Required

Email * Required

What is your current living situation?

i.e assisted living, residential house, apartment, with family, alone, etc.

What type of senior living option(s) 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 days and times.

Note: these dates can be discussed more in depth during our next phone call.

Who is your primary care physician? * Required

Share your primary care physicians phone number: * Required

Do you take any medication? If so, which kind? * Required

Health Status: Describe health condition(s) * Required

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

i.e pets, smoking, etc.

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

How did you hear about us? * Required

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