ard sTRATEGIES for seniors providing FREE

SENIOR PLACEMENT SERVICES TO FAMILIES!

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Kowalian Foundation
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Home
About Us
Memory Care
Senior Expo
Silver Linings
Kowalian Foundation
Contact
Blog
Careers
FAQ

Intake Form

Feel free to contact us with any questions or concerns. You can use the form on our website or email us directly. We appreciate your interest and look forward to hearing from you.

First Name*

Last name

Phone:

Your email*

Please select any services that you believe are required for the Recipient. (Select all that apply) *

Daily assistance with everyday tasks (Eating, Bathing, Dressing, Toileting ,etc.)

Geriatric Assessment / Evaluation

Health-related services (e.g., help with managing medications) 3

Hospice Services

Meal Preparation

Minimal skilled nursing services

Rehabilitation services

Visiting Physician / House Calls

Visiting / Private Duty Nursing

Does the Recipient need price quotes and/or information on any of the following? (check all that allply)*

Final Expenses

Financial Planning

Long Term Care Coverage

To whom are you interested in getting information regarding our services? (Please select one) *

Self

Spouse

Parent

Grandparent

In-Law

Sibling

Other Relative

Friend

Is the Recipient Male or Female? *

Male

Female

What is the age of the Recipient>*

When would you like services to begin? *

Immediately

Within 2 weeks

Within 4 weeks

Within 8 weeks

What, if any, existing medical conditions does the Care Recipient have? *

ALS

Alzheimer's / Dementia

Arthritis

Cancer

Colostomy

Depression

Diabetes

Heart Disease

High Cholesterol

Hypertension / High Blood Pressure

Incontinence

Joint Replacement

Macular Degeneration

Osteoporosis

Parkinson's Disease

Respiratory Disease

Stroke

Surgical Recovery

Disease or a Condition not listed here

None or Unsure

Which of the following best describes the recipient's current living arrangement? *

At home living independently

At home with some services in place

Assisted living facility

Independent living facility

Skilled nursing facility / nursing home

Hospital or rehabilitation facility

How would you describe their feelings about receiving assistance? *

Very Receptive

Somewhat Receptive

Resistant to Help

Unaware

Additional Information