In-Home Care (Caregiver)

Thank you for your interest!
We offer FREE assistance in helping families find the best Home Care option to seniors, who prefer to stay in the comfort of their home as an alternative to moving to an Assisted Living community.

Let us help – at NO COST to you!

To better serve you, please complete the Needs Assessment form below. This will help us process your request quickly and send you a customized list of options matching your care needs and preferences.

Client Information:

Find Senior Care

Please tell us what you are looking for.

Call Smart Senior Living

Toll Free:(800) 585-8605

Email: advisors@smartseniorliving.net
Website: www.smartseniorliving.net

Your First Name *:
Your Last Name *:
Home Phone *:
Work Phone:
Cell Phone:
Email Address *:
Street Address:
City:
State :
Zip Code:
Contact Preference (Check all that apply):	Home Phone Cell Phone Work Phone Email
Best Time to Call:
Relation To Senior:
Senior's First Name:
Senior's Last Name:
Gender:
Senior's Age:
Senior's Current Location:


City:
State:
Walking Ability:
Toileting
Mental Condition:
Is this request for service for a couple?
Secondary Care Recipient's First Name:
Last Name:
Age:
Existing Medical Conditions and Requested Services:
Monthly Budget?
Source of Funding to pay for the cost of Care?:	Select Private Pay Long Term Care Insurance Other( please specify)
Urgency of Need:	Immediately Within 2 weeks Within 4 weeks Within 8 weeks 3-6 Months Uncertain, just gathering information
Service Hours required / day choice of:	4 hours 4-8 hours 8-12 hours over 12 hours 24 hours (Live-In) Other
Comments:
May the Facilities contact you if they have questions or perhaps to personally invite you for tours:
How Did You Hear About Us?
Whom Should We Thank?

	Senior Housing (Retirement, Independent and Assisted Living, Alzheimer's Care, Board and Care Homes)
	In-home care (Caregiver)
	Other