Initial Consult | Geriatric Planning

Referral Type Required

Client - placed

Prospect - not placed

Baseline Assessment

Comprehensive Assessment

THERE is another family member included in this referral

If Client lives in a Community, what level of care? Required

Independent

Assisted Living

Memory Care

Continuous Care Community

If Client lives at home, what level of care? Required

Client lives alone with no care.

Primary provides for care needs.

Additional care provided by other family/hired caregivers.

If Client lives at home, what level of care? Required

Contact provides their care.

Additional family help with care.

We hire caregivers.

We need help finding care providers.

We need help to know what care is needed.

Other, explain in Additional Comments

In what city do you live? Required

How did you hear about Geriatric Planning? Required

Google search

Geriatric Planning website

Dementia Specialist website

An association referral list, please provide association name in Additional Comments

I'm a returning client

If referred by a client or a friend, please provide their name in Additional Comments

Other, explain in Additional Comments

Does your loved one have?

Long Term Care Insurance

Healthcare POA