Senior Resource Care Services
Senior Resource Care Services
1. Requestor's Information
Full name:
Address:
 
City:
State:
ZIP:
Phone number:
Alt. phone number:
Email:
What kind of services are you interested in?
 In-Home companion and personal caregiving 
 Placement and Referral assistant to a care community 
 Nurse Consultation 

Relationship to client:
Best time to contact you:


2. Client's Information
Full name:
Current location:
Address:
 
City:
State:
ZIP:
Age:
Weight:
Smoker:  Yes   No 
Drinker:  Yes   No 
Likes pets:  Yes   No 
Allergies:  Yes   No 
Please list allergies:

Likes activities:  Yes   No 
Please list activities:




3. Medical Information
Current medical concerns:

 Heart   Lungs   Neurological   Other 

Please explain:


Dietary comments:


Personality:
Hearing:
Vision:
Incontinence:  Yes   No 
If yes:  Bladder   Bowel 
Dementia:
Up at night:  Yes   No 
Needs assistance:  Yes   No 
Other concerns:




4. Desired Location
Choice 1:
Choice 2:
Choice 3:
When should the move be?


5. Financing
How do you plan to pay for your care needs?





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Help from the heart for those in need
Senior Home Care and Long Term Housing Options

Senior Resource Care Services offers senior home care services and free referrals for assisted living, long term senior housing, nursing homes, and adult family homes.  Serving Western Washington, King County, Snohomish County, Everett, Seattle and Bellevue.

If you have any questions, please contact 425.423.9512 or Toll Free: 1.888.791.4111 - Email: info@seniorresourcecare.com

Senior Resource Care Services - www.seniorresourcecare.com
3015 51st Place SW, Everett, Washington 98203

Senior Resource Care Services. Copyright 2004