Assurety Residence Information Form
(Ex: assisted living, nursing home, independent living, or senior community)


CONTACT INFORMATION

Please provide the following information for the person completing the needs survey and requesting results.

Fields with * must be completed
Salutation:
* First Name:
* Last Name:
* Zip Code:
Phone: -
* Email:

Please provide the desired location for the service(s) to be provided:
* City:
* State:
* Zip:

Please select your preference for where care is to be provided:
(Please select all that apply)
Independent Living / Senior Community Adult Day Care Facility
Assisted Living Facility Group Home / Residential Care Home
Skilled Nursing Facility / Nursing Home Continuing Care Retirement Community

Please select any services that you believe are required for the Care Recipient:
(Please select all that apply)
Adult Day Care / Respite Care Hospice Services
Geriatric Assessment / Evaluation Meal Preparation
Home / Safety Monitoring Rehabilitation Services (e.g. Physical Therapy)
Homemaker / Household Services Transportation Non-Medical (e.g. Errands, Shopping)
Personal Care (e.g. Bathing or Toileting) Transportation Medical (Non-Emergency)
Visiting Physician / House Calls Visiting / Private Duty Nursing

Do you need or want any of the following Consulting / Advisory Services?
(Select all that apply)
Assurety Placement Services
Family Counseling
Long Term Care Planning

Does the Care Recipient need price quotes and/or more information on the following?
Long Term Care Insurance

What funding source will be the primary payer for the services?
(Please select one)
Private pay Medicaid / Public Assistance
Medicare Long Term Care Insurance
Combination (Private Pay & Medicare)

Many Assurety services are not covered by insurance, Medicare, Medicaid or public assistance. As such, are you willing to pay "out-of-pocket" for part or all of the services you requested?
(Please select one)
Yes No

How much have you budgeted for these "out-of-pocket" expenses?
(Please select one)
$500 to $1,000 per week
$1,000 to $1,500 per week
Over $1,500 per week


CONSUMER NEEDS SURVEY

For whom are you interested in getting information regarding Assurety services?
(Please select one)
Self In-Law
Spouse Sibling
Parent Other Relative
Child Friend
Grandparent

Please provide the following information about the Care Recipient
Gender:
Age:

When would you like services to begin?
(Please select one)
Immediately Within 4 Weeks
Within 2 Weeks Within 8 Weeks

Please indicate the number of hours of support services that you estimate the care recipient requires.
(Please select one)
More than 100 hours per week 10 to 20 hours per week
40 to 100 hours per week 0 to 10 hours per week
20 to 40 hours per week

What, if any, existing medical conditions does the Care Recipient have?
(Select all that apply)
ALS Incontinence
Alzheimer's / Dementia Joint Replacement
Ambulatory Problems Macular Degeneration / Low Vision
Arthritis Other Eye Disorders & Diseases
Cancer Osteoporosis
Colostomy Parkinson's
Depression Respiratory Disease
Diabetes Stroke
Heart Disease Surgical Recovery
High Cholesterol Disease or Condition Not Listed
Hypertension / High Blood Pressure None/Unsure

Which of the following best describes the Care Recipient’s current living arrangement?
(Please select one)
At home and living independently Skilled nursing facility / nursing home
At home with some services in place Hospital or rehabilitation facility
Assisted living facility

How would you describe Care Recipient’s feelings about receiving assistance?
Very Receptive Resistant to Help
Somewhat Receptive Unaware

Do you have a preference on how you would like to be contacted?
(If so, please select one)
Email Phone No Preference

Please include any additional information that you think may prove helpful in matching your needs with our network of providers.