To help us better understand your Assisted Living Needs, or the needs of your loved one, please complete the following Assisted Living Inquiry Form. 1Legally Responsible Person and Applicant2Assisted Living Needs and Preferences3Financial Information1/3Legally Responsible Person and ApplicantLegally Responsible Person First Name Last Name Email Phone Best Time to Contact Relationship to Applicant Applicant Same as Legally Responsible Person First Name Last Name NextPlease provide the following. optional, but insightful information Street Address City State Zip Code Applicant Current Living Situation Reason for Seeking to Change Select all the activities the applicant needs assistance with Housekeeping Meal Preperation Medications Dressing Grooming Ambulation Confusion Hearing Speech SmokingHabits Transportation SpecialDiet NursingCare Bathing Toileting Transferring Wandering Vision Social Emotional Other Needs Religious or Cultural Location Pet Hospitalized in the Past 30 Days---YesNo Discharge Date Veteran---YesNo Memory Care Type BackNext Financial Information Public Program Types Public Program Total Amount Private Funding Sources Private Funding Total Amount Back