ALL for Seniors Questionnaire

Please complete this questionnaire with as much information as you can so ALL for Seniors™ can provide the best available information for potential residents. The more information you provide, the more likely you will be contacted. Thank you!

You may also print out this questionnaire here: ALL for Seniors questionnaire

Your Contact Information
  1. (required)
  3. (required)
  6. (valid email required)
About Your Senior Housing Residence
  1. Describe the type of care offered:







  6. Is there a Waiting List?
  8. Management on Site?
  11. Accreditations/Memberships:





Medical Services
  1. Nursing Care:
  2. Staffed 24 Hours?
  5. Licensed RN/RPN on site?
  7. Medication:
  8. Administered
  10. Supervised
  12. Physician Care:
  15. Pharmacy on-site:
  17. Assisted Daily Living Care (help with bathing, grooming, dressing, etc)
  21. Outside Professional Services allowed: (dental, optical, physical therapy, etc.)
Alzheimer/Dementia Care
  1. Do you provide care for Alzheimer's disease &/or Dementia:
  4. If yes, please complete the following:
  5. Where do residents with Alzheimer's disease &/or Demential live at your residence. (dedicated building or care unit)
  7. What special services are supplied to residents with Alzheimer's disease &/or Dementia? (daily planned activities, specialty trained staff, etc.)
Suite Features
  1. One bedroom
  4. One bedroom plus den
  7. Two bedroom
  10. Private bedroom & shared bath
  13. Shared bedroom & shared bath
  16. Additional Fees:



  20. Can couples room together?
  23. Temporary or Short Term Option(s):



  26. Can residents bring their own furniture?
  30. Are there Guest Accommodations available?
  34. Room Amenities: (check all that apply)






  37. Housekeeping/Towel and Linen Service:
Dining Amenities
  1. Central dining area:
  4. Private dining area:
  7. Dietary options: (check all that apply)



  10. Is there a Dietician on-site or available for counseling?
  13. How many meals are provided each day?

  16. Can residents choose to dine in their suite?
Other
  1. Are any of the following amenities available at your residence? (check all that apply)








  4. Pets allowed?
  8. Smoking allowed?
  12. Does your staff require criminial background checks?
  15. Parking/Travel options: (check all that apply)


  18. Your staff also speaks, other than English:


One last thing...
  1. Does your residence offer anything that potential residents may find interesting and unique? If you have a descriptive paragraph used in other advertising (e.g. the Careguide source for seniors, Senior Living, etc.), you may put it here and it will be posted alonside your contact info.
  3. Thank you so much for your time to complete this questionnaire. It is my intention to provide your potential clients as much information as possible so they will contact you.
  4. I have read and agree to the"Terms of Service"
 

cforms contact form by delicious:days

ALL for Seniors™

Change the font size
Search for Accommodations

Any All
Search for Realtor Listings

Any All
Featured Care Facility

Terms of Use | ALL for Seniors Questionnaire | Provider Order Form
About Me | Contact Me
Copyright © ALL For Seniors. All Rights Reserved.

Login
Designed by e-motional web design | Copyright © 2012