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17037 Chatsworth Street Suite 206 Granada Hills, CA 91344
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About Us
Services
Senior Living Options
Helpful Resources
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Questionnaire
Please submit the information and one of our team members will reach you.
Senior’s Name
Contact name
(if other than the senior)
Relationship to senior
Phone Number
Email
Care Needs
Does the senior live at home?
Yes
No
Does the senior need placement?
Yes
No
Address
ALZ/Dementia
Yes
No
ALZ/Dementia
Early Stage
Mid Stage
Moderate
Diabetic
Yes
No
Diabetic
Insulin
Oral
Medication management help?
Yes
No
Bathing help?
Yes
No
Dressing help?
Yes
No
Incontinent Care?
Yes
No
Feeding Help
Yes
No
Any special Diets
Yes
No
Mobility:
Independent
Walker
Wheelchair
Bedbound
Does the elderly need food?
Yes
No
Does the elderly need shelter?
Yes
No
Does the elderly need grab bars installed?
Yes
No
Does the elderly need cellphone?
Yes
No
Does the elderly need medical alert system?
Yes
No
Does the elderly have a dedicated caregiver?
Yes
No
Submit
