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Silver Bridge Placement – Comprehensive Needs Assessment Form

Hey there! Thank you for contacting Silver Bridge Placement. We're a comprehensive Senior Care placement and advisor service.

Please answer every question with as much detail as possible. Thank you for choosing Silver Bridge Placement.

Full Name of Prospective Resident?

*

Date of Birth

*

Primary Contact Name

*

Relationship to Resident

*

Best Phone Number

*

Best email address?

*

Current Living Arrangement

*

Why is the family exploring senior housing now?

*

Has the resident had any recent hospitalizations, falls, or medical events?

*

If yes, describe:

*

What type of support is the resident expected to need?

*

What type of support is the resident expected to need?

Independent Living (minimal support, social lifestyle)

Assisted Living (ADL support, medication reminders)

Memory Care (supervision for dementia/Alzheimer’s)

Respite/Short-Term Stay

Skilled Nursing (clinical medical care)

Untitled checkboxes field

Residential Care Home

In-home Care Options

Has the resident been diagnosed with any cognitive impairment?

*

Has the resident been diagnosed with any cognitive impairment?

No

Mild Cognitive Impairment

Early-Stage Dementia

Moderate Dementia

Advanced Dementia

Alzheimer’s Disease

Mobility Level

*

Mobility Level

Fully Independent

Uses Cane

Uses Walker

Wheelchair (self-propel)

Wheelchair (assisted)

Bed-bound

Assistance Needed with ADLs

*

Assistance Needed with ADLs

Bathing

Dressing

Grooming/Hygiene

Toileting

Meal Preparation

Medication Management

Transfers

Incontinence Care

None

Any history of wandering or exit-seeking?

*

If yes, describe:

*

Any behavioral or safety concerns?

*

If yes, please provide context:

*

Primary Medical Conditions

*

Current Medications

*

Medical Equipment Needed

*

Medical Equipment Needed

Oxygen

CPAP

Feeding Tube

Hoyer Lift

Catheter

Other

Physician or Specialist Involvement

*

What is the expected monthly budget for care?

*

What financial resources are available?

*

What financial resources are available?

Private Pay

Long-Term Care Insurance

Veterans Benefits (Aid & Attendance)

Medicaid

Pension/Retirement Income

Real Estate Sale Proceeds

Family Support

Other

Does the resident have Long-Term Care Insurance?

*

If yes, specify benefits:

*

Preferred Geographic Areas

*

Proximity Preference

*

Proximity Preference

Near adult children

Near medical providers

Near current home

No preference

Unit Type Preferences

*

Important Amenities

*

Important Amenities

Private bathroom

Kitchenette

Dining services

Transportation

Social activities

Fitness programs

Religious services

Pet-friendly

Outdoor spaces

What outcomes does the family hope for with this transition?

*

Any cultural, religious, or personal preferences we should be aware of?

*

Family involvement preferences

*

What is the desired move-in timeline?

*

What is driving the timeline?

*

Who is the primary decision-maker?

*

Who is the primary decision-maker?

Resident

Adult Child

POA / Legal Guardian

Joint Decision

Does anyone hold Power of Attorney?

*

If yes:

*

Is there anything else we should know to best support your family?

*

Referred by: Intake Specialist

*

Phone Number

*

Email

*

Thanks for patiently answering all the questions. Someone will contact you soon.