Client Intake Form

Primary Contact *

Who is filling out this form?

First Name

Last Name

Phone

(###)

###

####

Relationship to Senior:

Self

Adult Child

Guardian

Power of Attorney

Other

Full Name of Senior *

First Name

Last Name

Senior's Current Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Current living situation:

Own home

Rental

With family

Hospital/Rehab

Other

Preferred language

English

Spanish

French

Other

Is the senior aware and onboard with the transition?

Yes

No

Partially

Transition Details

What kind of move is being planned?

Senior Apartment

Independent Living

Assisted Living

Memory Care

Other

Ideal Move Timeline

ASAP

1-3 months

3-6 months

Just exploring for now

Current home status

Owned

Rented

Family-owned

Do you plan to:

Sell the home

Rent it out

Liquidate belongings

Keep it in the family

Do you need help with:

(check all)

Home sale

Downsizing and organizing

Estate sale

Cleaning and repairs

Staging the home

Moving and logistics

Temporary housing

Finding a new residence

Family Support

Are there other family members involved in the process?

No

Yes

Who will be the primary decision-maker?

First Name

Last Name

How did you hear about us?

Referral

Online search

Assisted Living facility

Social media

Community event

Other

Preferred contact method

Phone call

Text

Email