Assessments

Assessment Type

First Name

Last Name

Phone/Mobile

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Assessment Type

Is There An Immediate Need For Move-In

Type Of Living Style

Availability

Pricing

Amenities Requested

Levels Of Care

Fees For Service

Allow Hospice Care

Notes

Client Signature

Date Contract Signed (Client)

Agent Signature

Date Contract Signed (Agent)

Current Primary Provider

Specialty Provider?

Do you use any assistive devices?

List Medical/ Mental Diagnosis

List Previous Surgeries/ Upcoming Surgeries

Medications

List Allergies

Do you drive?

Do you have access to transportation?

List All Assistive Devices

Oxygen: How many Liters and which company?

Where is your pain located? Rate your pain from 0-10

What is your highest level of education?

Please List Any Concerns You Have:

Date Of Last Medical/ Vision/ Dental/ Hearing Exams

How many meals do you eat each day? Are your meals healthy?

How many hours of sleep are you getting each night?

Have you had any recent losses within the past 6 months to a year?

Do you have Depression, Anxiety, hallucinations, Delusions, Alzheimer's, or Sundowning Syndrome? If so, how do you deal with them?

Can you think clearly without any assistance?

Is your Thought process delayed?

Do you feel safe in your current environment?

Mobility:

Do you have any issues paying your bills?

Do you have any extraneous expenses that?

Is your housing stable?

Are your utilities working in your home?

Are you planning to move soon?

If you require housing, what type of housing would you prefer, and what is your monthly budget?

Do you have sufficient space?

Does your home need any repairs?

Do you need assistance with bathing or any activities of daily living?

Who is your insurance carrier?

Do you have long-term health insurance coverage?

Do you have a Power of Attorney? If so, who is your Power of Attorney?

If No: Who can we call in case of emergencies?

Do you have a medical Power of Attorney?

Do you have a complete POLST form?

Please list your hobbies:

Initial Senior Placement Facility Assessment

Regal Seniors Resources is a concierge seniors nursing agency that provides assistance with placement. With love and compassion, we help families connect to assisted living placements, independent living homes, long-term care nursing homes, and retirement communities. Aging with love, grace, & legacy is our priority.

Before we discuss senior placement and the process of planning a transition for an older adult, we need to learn more about your facility.

Please note that we are located in Atlanta, Georgia. Reply with “N/A” if needed but record a response for all sections. Please take 10-20 minutes to complete this free and brief questionnaire.

After completion, our owner and senior placement advisor will contact you for a virtual meeting. This information is confidential and will only be shared with staff/contracted parties of Regal Senior Resources.

Thanks so much...

Name of Your Facility:

Facility Owner/Contact Person:

Facility Location(s):

Address Line 1

Address Line 2

City

State

Zip Code

Country

Email:

Website

Social Media Links:

Type of Placement:

Other

Please list your offered services:

What are your staffing levels? (RN, GNA, social worker, LPN, etc)

What is your resident to staff ratio?

Describe your level of assistance with ADLs for your residents: (light assistance, moderate, max assist, bedbound, two person assist, BARIATRIC)

Is your facility equipped and ADA compliant with wide doorways, wheelchair ramps, grab bars, etc? Please describe:

Do you participate in homebound services of PCP programs, prescription delivery, geri-psych, etc?

Does your placement offer a calendar of social activities and different food menu items?

Do you offer case management and care coordination services? If not, please share your interests.

Do you offer care plan meetings for your residents?

Please list your licenses for your facility?

Please share any additional information that may be helpful.

If we enter into a contractual agreement, can we share about your facility on our social media pages and website?

Regal Seniors Resources is a senior placement agency. We assist families with being placed at a facility of their choosing. If they select your facility with our assistance, we will receive 80% of the new residents’ first month rent only. Prior to the move in, we will provide the residents’ nurse case management assessment for your review. At the residents’ 30-day mark, we will also facilitate an initial care plan meeting and follow up resources. As a courtesy your facility can also participate in our virtual caregiver support group for resources. Are you in agreement with these terms?

First Name

Last Name

Date Of Birth

Record ID

Session Date

Mins:

Unit

Case Manager:

Program:

Mgt. Location:

Address Line 1

Address Line 2

City

State

Zip Code

Country

Diagnosis

Danger to:

Status

Response to TX:

Notable Changes Since Last Session:

Appearance

Judgment

Insight

Speech

Thought Process

Thought Content

Mood

Behavior

Stratifying Risk

Notes

Services/Interventions

Screening

Assessment

Planning

Care Coordination

Transitional Care

Immediate Needs

Goals/Objectives

Upcoming Appointments

Referrals

Successes

Assigned Homework

Additional Notes

Next Appt:

Date

Initial Senior Placement Facility Assessment

Give Your Loved Ones Quality Care You Can Trust

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