Locate a Senior Home
In order to assist you, Senior Seasons needs the following information. Please complete this form or call us at
650-851-5284
.
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I am looking for a home for
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Myself
Couple
Parent
Parents
Relative
Friend
Type of accommodation
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Private apartment
Shared apartment
Private room
Shared room
Flexible/Don't know
Size of home or community
Select
Under 15 residents
Under 50 residents
More than 51 residents
Flexible/Don't know
*
Any assistance needs
None
Meds management
Transportation
Escort
Walk assist
Incontinent care
Bathing/dressing
Dementia/Alzheimer
Secure perimeter
Special diet
Other
Diagnosis
Any special considerations
Pet
Select
Cat < 30lbs
Dog < 30lbs
Dog > 30lbs
Other
Other Pet
Smoker
Yes
No
Vision
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Good
Slightly impaired
Very impaired
Hearing
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Good
Slightly impaired
Very impaired
Speech
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Good
Slightly impaired
Very impaired
Primary Language
(If other than English)
Likes/dislikes/preferred amenities
*
Preferred city or area
Or within
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5
10
20
30
Miles
*
Age of Senior
*
Gender
Male
Female
*
Monthly budget
$
Select
1000
2-3000
3-4000
4-5000
Over 5000
Plan to move within
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1 month or less
3 months
6 months
1 year+
Not sure
Contact Information
*
First name
*
Last name
*
Street
*
City
*
State
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AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
*
Zip
*
Primary phone
Alternate phone
*
Email
Name of Senior or Seniors if different from Contact
*
First name
*
Last name
Street
City
State
Select
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
Primary phone
Alternate phone
Email
Would you like brochures sent to you from the Senior Homes?
Yes
No
*
Best way for Senior Seasons to contact you
Phone
Email
U.S. Mail
Other
May Senior Homes contact you by
Phone
Email
U.S. Mail
Other
Do not contact
Senior Seasons looks forward to helping you. Please provide any additional information or comments that may help us with your search.
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