CONTACT US

Questions? Want more information? Please use the form below to contact us by email with any questions or concerns you may have. Of if you would like to contact us directly, give us a call at 602 524-5072.
* = Required fields

Contact Information
* Name:
* Prospective Client Name:
* Home Phone:
* Cell Phone:
* Email:
Comments:
ADDITIONAL (Optional) INFORMATION:
Desired Location:
     What type of accommodations are you looking for?     (select all that apply)
Alzheimers-Dementia Care
Assisted Living Facility
Adult Group Home
Independent Senior Living Community
Not Sure
     Does the prospective client use any assistive devices?     (select all that apply)
Cane
Walker
Wheelchair
Electric Wheelchair-Scooter
Other
     Do they require assistance with any of the following?     (select all that apply)
Bathing
Eating
Tranferring
Toileting
Medications
Walking or ambulation
     Does the senior suffer from any of the following?     (select all that apply)
Impaired Vision
Incontinence
Hearing Deficits
Falling
     Does the senior suffer from any memory impairment?
     What is the monthly budget or price range being considered?     (select all that apply)
$1500-$1999
$2000-$2499
$2500-$2999
$3000-$3499
$3500-$3999
$4000+
     Is ALTCS (Medicaid planning) a likelihood or necessity?

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