Prospect Information Form
1.
Please input this data so we may  begin assisting you with your research.

By entering my personal information, I consent to receive email communications from the survey author's organization based on the information collected.

First Name:
Last Name:
Company Name:
Work Phone:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
City:
State/Province
(US/Canada):
Postal Code:

2.
Number of Bedrooms:
1
2
3
  • Comment:

  • 500 character(s) left.
3.
Number of Bathrooms
1
1.5
2
2+
Other  
4.
Area Desired:
Urban
Rural
Close to Relative
Other  
5.
Number of Persons to Live There:
1
2
Other  
6.

Monthly Rental Budget:
$500-$900
$1000-$1,800
$1,900-$2,500
$2,600-$3,000
$3,100-$4,000
$4,100-$6,000
$6,100-$8,000
$8,100+
Other  
  • Comment:

  • 500 character(s) left.
7.
Types of Rental:
Lease
Month-to-Month
Co-op
Emergency/Urgent
Other  
8.
Do you want your medical-documents digitalized and stored for future reference?
Yes
No
Maybe. Send more information
9.
When do you want to look for a new home/apartment/facility?
As Soon as Possible
1 Month
2-6 Months
6 Months - 1 Year
1 Year+
  • Comment:

  • 500 character(s) left.
10.
Monthly Gross Income:
 

  • 50 character(s) left.
11.

Former Occupation:
 

  • 50 character(s) left.
12.
Incontinence Program:
Yes
No
Maybe. Send me information
13.
Skilled Nursing Care:
Yes
No
Maybe. Send me information
14.
Medication Management:
Yes
No
Maybe. Send me information
15.
Pet Type:
Dog
Cat
Bird
Other  
16.
Are there additional attributes that you would want in a Senior Living, Assisted Living or Nursing Home that are important to you or your Senior one?
 

  • 350 character(s) left.