About the person

The senior or family member this is regarding.

Who is this support for? — Select — Myself Parent Other family member Age range — Select — Under 65 65–74 75–84 85+ Current living situation — Select — Living independently at home Living at home with support Living with family Assisted Living Memory Care Other City or area

Care needs

Helps us understand the right level of care.

Care type of interest — Select — Assisted Living Memory Care Independent Living Not sure yet Memory or cognitive concerns? — Select — None Mild / early Moderate Significant Mobility — Select — Independent Uses walker Wheelchair Varies Medication management needs? — Select — Manages independently Some assistance needed Full assistance needed

Preferences & budget

Helps us recommend communities that fit.

Monthly budget range — Select — Under $5,000 $5,000 – $7,000 $7,000 – $10,000 $10,000+ Still exploring Location preferences Must-haves or deal-breakers

Timeline & next steps

When are you looking to make a decision?

Timeline — Select — Urgent (within 2 weeks) 30–90 days Just exploring Best time to call — Select — Morning Afternoon Evening Any time Anything else we should know?