Confidential Information Form

In order to serve your needs fully, it is helpful for us to have the following information available prior to our initial in person meeting with you. That meeting may take place either in the hospital or care facility where the senior is presently, or if at home, at their home. You may either fill this form out online and hit submit, or print and fax it to us at 503-907-6644. Please indicate the best time for us to reach you. We will respond soon after receiving this information. At the same time, don’t hesitate to just call us and we can talk you through this information. Thank you.

All fields marked with an * are required fields and must be filled out.





*Contact Name

*Contact Email Address

Subject

*Primary Contact Person

*Seniors Name (Person Needing Care)

Sex

Age

Height (approx if not sure):

Weight (approx if not sure):

Present Location

Other

Name of Hospital or Facility:

*Primary Contact Person:

*Relationship:

*Home Phone:

Cell:

Secondary Contact:

Relation:

Home Phone:

Cell:

Any Additional Information that would be helpful to us in order to recommend the most appropriate setting?

Cognitive Ability:

Behavior:

Mobility at this time?:

Bathing:

Night Needs:

Bladder Issue:

Bowel:

Is the Person Diabetic:

Eating:

Area Most Desired?:

What type of Care Setting is Preferred?:

Additional Desires:

Desires Other:

Financial Status:

Within:

Period:

Additional Information/Needs: