Keepsake Choices - Contact Us

KEEPSAKE CHOICES

Contact Us

Your Information

Client Name:
Age:
Contact Name:
Contact Relationship:
Contact Phone:
Contact Email:
Mailing Address:
City/State/Zip:

Mental Condition

Alert?	Yes	No
Memory Problems?	Yes	No
Diagnosed with Dementia/Alzheimer?	Yes	No

Social Factors

Enjoys Socialization?	Yes	No
Ability to Drive?	Yes	No
Pets?	Yes	No
Smokes?	Yes	No

Assistance Needed

Reminding
Transportation
Walker
Wheelchair
Cane
Bedridden
Oxygen
Medication Management
Grooming
Shower / Bathing
Toileting
Injections
Continence Care
Other

Level of Care

Skilled Nursing
Assisted Living
In Home Care
Independent Living
I am not Sure

Monthly Rate (Housing & Care)



Preferred Location

Within 5 miles of
Studio Apt.
One Bedroom
Two Bedroom

Time Frame