Ruth A. Lemerand Senior Housing Placement


Senior Name:
Age:
Where is your senior currently living?:

Senior Health Information:
Dementia/Alzheimer's:
Mobility:

Senior Financial Information:
Financial Resources:
Able to afford per month:

Daily Activity Help:
Getting dressed:
Taking a bath or shower/Grooming:
Medication Management:
Able to feed self:
Wearing Briefs (Diapers:)

Preferences:
Type of Senior Housing/Care Community you are in need of:
Type of Living Area Desired:
I would like for the senior community to offer:
Desired location of new home:	(ex. La Jolla, CA)

Important Information Needed to Assist You:
Salutation:
Title:
First Name:
Last Name:
Email:
Phone:
Work Phone:
Fax:
Mobile Phone:
Address:
City:
State:
Zip:
How Senior is related to you:
I found Ruth Lemerand Senior Housing Placement via:
How quickly are you looking for senior housing?:

Please give us any additional information that will assist us in our search on your behalf. Feel free to submit any questions or concerns you would like us to address:


Be sure you enter your first and last name, e-mail address and the best telephone number you can be reached at, so we may be able to assist you promptly.
All your information is kept private & confidential.