Senior Choice

Placement Questionnaire for Family

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

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Your First & Last Name * Required

Your Phone Number

Your Email

Name of person for whom I will be inquiring: * Required

Their Approx. Height & Weight * Required

Their Birthday * Required

Their Gender * Required

What's their current living situation?

i.e memory care, board & care, private home, etc.

What 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 during our next phone call.

Who is their current primary care physician? * Required

Share their primary care physician's phone number: * Required

Are they taking any medication? If so, list them below. * Required

Are they sleeping through the night? * Required

Sometimes

Yes

Do they wander? * Required

Sometimes

Yes

Health Status: Describe their current condition(s) * Required

Share more information you think would help me better understand them or your situation:

How did you hear about us? * Required

Less Annoying CRM

Thanks for filling out our questionnaire! I have received your answers and will get in contact with you shortly.

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