Lead Collection Page – Senior Placed

Who is in need of senior care? *SpouseParentMyselfSomeone else

What is your loved one’s age? **Due to senior living community requirements, we are only able to assist those 55 years and older.

Street Address *Please enter the primary location for your search even if you are open to a few different areas.

City *

State/Province

ZIP / Postal Code *

What is the maximum distance you are willing to travel from your preferred location? *Under 5 miles10 miles15 miles20 miles25 miles30 miles50 miles and over*It’s important to take into consideration the type of area you live (urban, suburban, rural) when considering the travel time to visit your loved one.

Where is your loved one living now? *Home (lives alone)Home (lives with someone)Assisted LivingHospitalNursing Home / Rehab Facility*Why we ask: There is a natural desire to stay independent for as long as possible. Environments that provide easy access to assistance if needed can provide a balance of independence and safety.

How is your loved one's mobility? *IndependentWalkerCaneWheelchairImmobileBedridden*Understanding your loved one’s mobility can help us match them to the right type of community.

What are your room preferences within a community? *StudioOne bedroomTwo bedroomsPrivateShared*There are a range of room types available at each community based on your budget and lifestyle preferences.

What is the total cost of care you believe your loved one/your family can afford for senior living? *Less than $2,000$2,000 - $2,499$2,500 - $2,999$3,000 - $3,999$4,000 - $4,999over $7,000*Senior living costs vary depending on location and services provided. Total costs of care typically include the cost of accommodations and food plus the cost of services such as personal care, social and recreational, health and wellness, transportation, and acute care needs. Our advisor team can help with any questions you may have on maximizing your budget.

Is your loved one a Veteran or the spouse of a wartime Veteran? *YesNo*The Veterans Administration has an Aid and Attendance benefit for wartime Veterans and their spouses (including widows/widowers), who are US residents and financially qualified. The benefit may contribute to a portion of the cost of care services.

How do you or your loved one plan to pay for care? *RetirementFamily SupportHome to SellInsuranceVA BenefitsOtherOur expert Senior Living Advisors can discuss pricing for various levels of service, as well as the means of paying for care. They also have access to communities’ price flexibility and special promotions.

How quickly do you need to find care? *ImmediatelyWithin 30 daysWithin 60 daysNo rushWhether you have an immediate need or are just starting your search, our local Senior Living Advisors can provide availability and help schedule tours.

Your First Name *Please enter a valid first name.

Your Last Name *Please enter a valid last name.

Your Email Address *Please enter a valid email address.

Your Phone Number *Please enter a valid phone number.

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The Complete Guide
CONSIDERING SENIOR LIVING