Name*
Phone*
Address*
Email
Interested in Tour of nursing homeTour of apartmentsInformation about nursing homeInformation about apartmentsInformation about home care services
Who are you looking for? SelfParentAunt/UncleOther family memberFriend
If it is not self - Is he/she aware you’re looking? YesNo
Best method of contact PhoneEmail
Best time of day to contact
How did you hear about Crestview NewspaperRadioMagazineFriend or Family MemberCommunity EventGeneral Knowledge of the Community
Additional questions to help us give you specified information for your loved one:
Family member’s name:
Where does he/she currently live?
What are his/ her thoughts regarding a move?
What is most important to you/ your loved one in regard to the community you choose?
Tell us about his/her typical day
If we could do anything else to help improve his/her quality of life, what would it be? More socialization, eating better, exercise, etc.
What is your greatest concern at this time?
What does/ did your loved one do for fun?
Is anyone else going to be involved in helping you make this decision?
What kind of time frame are your considering?
