ASSESSMENT FORM

Fill out the senior care needs assessment form below so we can help you decide which senior living solution is best for you.

SENIOR CARE NEEDS ASSESSMENT FORM

Who are you searching for?

How soon will changes to you or your senior's current living situation need to be made?

Have you contacted or are you currently receiving assistance from any senior placement companies or agencies?

How much is safety a concern in your home environment?

How well are you managing daily bathing/showering, grooming, dressing, and personal hygiene functions?

Which statement best describes your continence and toileting abilities?

How well are you managing your medications?

How self-reliant are you with meal preparation, cooking, and eating?

How independent are you when moving around your home?

How capable are you in handling housekeeping and laundry tasks?

What is your transportation needs?

How would you describe your memory and level of mental awareness?

How do emotions affect your behavior?

6 + 11 =

AREAS WE SERVE

We currently provide senior placement services for residents to the following areas in San Diego County: Scripps Ranch, Poway, Rancho Bernardo, Rancho Penasquitos, 4S Ranch, Escondido, Fallbrook, San Marcos, Vista, Oceanside, Carlsbad, Encinitas, Solana Beach, Cardiff, Del Mar, Carmel Valley and University City. On occasion, we may be able to help you find a new senior community in other areas of San Diego County as well.

PHONE: 858-395-3333    FAX: 858-724-3348

Contact Next Step Senior Care Placement today for a free consultation on how we can guide you in taking your "next step" to find the perfect senior living solution for you or a loved one's needs!

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