START YOUR NEW CLIENT NEEDS ASSESSMENT

This form takes 10-15 minutes to complete, and it speeds up the process for your FREE consultation.

All information provided is optional and confidential. Senior Care Lifestyles will NOT share your information with any other parties without prior discussion and written approval from our clients.

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CLIENT PROFILE INFORMATION - Step 1 of 6

Inquirer Details

Name of Inquirer
Inquirer's Address

Senior's Details

Senior's Name
Gender
Sexual Orientation/Identity
DEFINITION: Sexual orientation is about who you’re attracted to and who you feel drawn to romantically, emotionally, and sexually. It’s different than gender identity. Gender identity isn’t about who you’re attracted to, but about who you ARE — male, female, genderqueer, etc. This means that being transgender (feeling like your assigned sex is very different from the gender you identify with) isn’t the same thing as being gay, lesbian, or bisexual. Sexual orientation is about who you want to be with. Gender identity is about who you are.
Seniors Address (If resides in own home)
Habitual Tendencies
Name of Assigned Social Worker / Case Manager: