Please Provide Key Information For Your Loved One

Name*

Who is in need of Senior Care [ ] Spouse [ ] Parent [ ] Myself [ ] Some One Else

Name of Family Member*

What is your Family Members age? [55 Years or Older]*

Where is your loved one currently living [] Home Lives Alone [] Home Lives with someone [] Assisted Living [] Hospital [] Nursing Home Rehab *

What is the maximum distance you are willing to travel from preferred location?

Is your loved one currently experiencing memory loss? [ ]Yes [ ] No*

What are your loved one's room preferences within a home? [ ] Own bedroom [ ] Shared bedroom*

What is the total cost of care you believe you can afford? [ ]$3,000 - $3,999 [ ] $4,000 - $4,999 [ ]$5,000 - $5,999 [ ]$6,000 - $6,999*

Is your loved one a veteran or the spouse of a veteran?*

Email*

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The purpose of this page is to collect basic information about person who would love to stay at My Grandma's House Adult Living Facility.

3185 Diego Aidan Drive, El Paso, Texas 79938, United States

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