Your Name

Phone Number

Email Address

Mailing Address

Inquiring For Inquiring ForMotherFatherMother-in-lawFather-in-lawGrandmotherGrandfatherSisterBrotherAuntUncleSpouseOther

Their Age Their Age64 or under65+75+85+

Level of Need Level of Need Urgent Looking for the Future

Current Living Situation Current Living Situation Own Home Home with daily nurse With friends/family Hospital Rehab Senior Community Other

Diagnosis/Health Situation Diagnosis/Health Situation Independent Stroke/TIA Parkinson’s Bone Fracture Dementia/Alzheimer’s Heart Disease/CHF Diabetes Other

Please Explain Current Living Situation

Please Explain Additional Diagnosis

Required Personal Assistance Required Personal Assistance Bathing Dressing Grooming Feeding Medication Management Toileting Incontinence Other

Needs/Conditions Needs/Conditions Blindness Speech Impaired Hearing Impaired Diabetic Management Injections Wound Care Oxygen Night Time Assistance Ostomy/Catheter Tracheotomy IV/Tube Feeding Hospice None Other

Mobility Mobility Independent Cane/Walker Wheelchair History of Falls Sit to Stand Lift Hoyer Lift Assistance Toileting Transfer Assistance with 1 Transfer Assistance with 2

Please Explain Other Assistance Needs

Needs/Condition Other

Mental Status Mental Status Sharp Confused Forgetful Social Wandering Agitated Evening Agitation Only Physically Combative Verbally Combative

Type of Community Type of Community Independent Living Assisted Living Memory Care AFC Home Respite Care Continuum of Care Skilled Nursing Low Income

Type of Unit Type of Unit Studio Semi-Private Private Bath 1 Bedroom 2 Bedroom 3 Bedroom

Amenities Amenities Meals Laundry Housekeeping Transportation Outings Activities Utilities Pets Smoking

Insurance Benefits Insurance Benefits Medicare Medicaid Medicaid Waiver Long Term Care Insurance Veteran Spouse of a Veteran Reverse Mortgage

Gross Income (per person) Gross Income (per person) Less than $1,000 per month $1,000 to $1,500 per month $1,500 to $2,200 per month $2,200 to $3,500 per month $3,500+

Savings/Annuities Savings/Annuities None Less than $10,000 $10,000 - $50,000 $50,000 - $100,000 $100,000+ Other

Geographical Preference Geographical Preference Downtown TC East TC West TC Old Mission Leelanau County Kalkaska County Antrim County Wexford County Other

Please Explain Other Geographical Preference