Free Referral Service for Seniors

Thank you for your interest!

We offer FREE assistance in helping families find the best available senior housing and elder care options. To find the RIGHT HOME, you will need the RIGHT PEOPLE working for you.

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:
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:


Facility Name:
City of Location:
Senior's Existing Medical Conditions and Assistance Needed:
Diabetes:
Walking Ability:
Toileting
Mental Condition:
Is Senior on Hospice?
Is this for a couple?
Monthly Budget?
Urgency of Placement:	Immediately Within 2 weeks Within 4 weeks Within 8 weeks 3-6 Months 6 mos. - 1 year Uncertain
Preferred Location to Move To (list up to 4 cities in the order of priority):
Preferred Type of Housing:	Independent Living Residential Home / Group Home Assisted Living (Large Facility) Respite Care / Short Term Stay Alzheimer's / Dementia Care Facility Secured / Locked Facility (for wanderers) Other
Preferred Room:	Shared Room Private Room Studio One bedroom Two bedroom
Comments:
May the Facilities contact you if they have questions or perhaps to personally invite you for tours:
Please list any facilities you have seen or contacted to avoid receiving duplicate information:
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