Community Inquiry Form

Contact Name: 

Property Name: 

Address: 

City: 

State:  CA AZ

Zip Code: 

Phone: 

Email Address: 

How many facilities do you operate? 

What kind of housing do you operate?
Retirement Living/Senior Living
Assisted Living - Number of beds: 
Alzheimer/Dementia - Number of beds: 
Skilled Nursing - Number of beds: 

Housing Information:

Gender:        Male and Female Female Male
Capacity:     
Price Range:
1 Bedroom
2 Bedroom
Studio
Private
Semi-Private

Level of Care Available and Additional Services offered?
Oxygen           Night Assistance        Smoking

Pets                Behavioral Problems  Mentally Ill

Respite Care   Assistance for Blind

Waivers and Exceptions Allowed:

Dementia/Alzheimer's

Hospice

Oxygen

Bed Rails

Bedridden 

Tell us more about your facility and/or UPDATED VACANCIES:

Thank you for taking the time to complete this form.  A consultant from A Senior Solution will be contacting you for further information and to add your community into our database.

"Helping families find the solution to their Senior Housing needs"