Care Survey

“Come to Me, all of you who are weary and burdened, and I will give you rest.”

– Matthew 11:28

Please fill out the following Harmony Care Survey in order to help us narrow down the list of possible living options to those that are the perfect fits for your situation. We’re so excited to be your trusted partners during this journey to ensure that you and your family find comfort and peace with your decision.

Let’s remember we all have bad days, but no one wants to be judged by them. When completing the following questions please give the response based on a normal day in your Loved One’s life.

Live in Harmony.

What is your Loved One's Name?

Date of Birth

Gender

Marital Status

Height

Weight

Cell Phone Number

Other Phone Number

E-mail

Client's Current Location

Location Type

Home (own)

Home (with family)

Hospital

Rehab

Assisted Living

Independent Living

Memory Care

Other

Discharge Date (if applicable)

Facility Name

Address

Street Address Address Line 2 City State ZIP Code

Living Situation Details

Best Contact Person

Which family member will be our main point of contact through this journey?

Name

First Last

Relationship to Loved One

Cell Phone Number

Other Phone Number

E-mail

Power of Attorney

Address

Street Address Address Line 2 City State ZIP Code

What's the best way to reach you?

Will there be other decision makers involved in this process?

Yes

Additional Contact(s)

Name

First Last

Relationship to Loved One

Cell Phone Number

Other Phone Number

E-mail

Power of Attorney

Address

Street Address Address Line 2 City State ZIP Code

Contact Notes

Will there be a third decision maker involved in this process?

Yes

Name

First Last

Relationship to Loved One

Cell Phone Number

Other Phone Number

E-mail

Power of Attorney

Address

Street Address Address Line 2 City State ZIP Code

Contact Notes

Living Preferences

Ideal Location Address

Want options near the best contact?

Street Address Address Line 2 City State ZIP Code

Location Notes / Other Preferences

How soon will you be making this transition?

Type of Living Option

Please, check all that apply.

In-Home Care

Independent Living

Assisted Living (resort style)

Assisted Living (residential home style)

Adult Family Care Home

Memory Care

Skilled Nursing

Hospice

Respite Care (a temporary stay)

Other Details

Smoker

Prefers a community that allows alcohol

Pets

N/A

My loved one has a dog

My loved one has a cat

My loved one will need assistance with pet

Are they still driving?

Yes

Yes, against advice

Preferred Amenities

Please, check all that apply.

Activities

Fitness Center

Optional Dining

Pool

Reading Materials

Secure Courtyard

Transportation Services

Walking Paths

Additional Notes Regarding Needs and Desires

Financials

Finding a budget for an assisted living facility is much different than looking at what you can afford for rent. The majority monthly expenses would be included in the rate you pay towards an assisted living facility and would no longer be factored into a monthly budget. We have worksheets and funding resources available to help you figure out a good amount for your circumstance if you're not sure. Your Harmony Advisor will use the following financial information to make sure we're helping you find a home that will be a long term solution.

Monthly Budget

Under $2,000

$2,001 to $3,000

$3,001 to $4,000

$4,001 to $5,000

$5,001 to $6,000

Over $6,000

Is your loved one a Veteran or spouse of a Veteran?

Yes

When were they in service?

Are they receiving or have they applied for the VA Aid & Attendance benefit?

Yes

Not Sure

Do you have their DD-214 (discharge paperwork)?

Yes

Not Sure

VA Benefit Notes

Does your Loved One have long-term care insurance?

Yes

Not Sure

Does your Loved One own their home?

Yes

Can your loved one manage their finances?

Independent

Can conduct basic transactions

Must be reminded to make deposits, write checks, pay bills, etc.

Needs assistance in every transaction

Requires a trustee or family appointed guardian to handle all financial arrangements

LTC (Notes)

Homeownership (Notes)

Financial Management (Notes)

Health Insurance

Primary Insurance

Additional Insurance Coverage

Activities of Daily Living

Let's remember we all have bad days, but no one wants to be judged by them. When completing the following questions please give the response based on a normal day in your Loved One's life.

Ambulation

Independent

Cane

Walker

Wheelchair

Power Wheelchair

Bedridden

Ambulation (Notes)

Ability to Transfer

Independent

Stand-by

1 Person Transfer

2 Person Transfer

Hoyer or sit to stand lift

Ability to Transfer (Notes)

Assistance Needed with:

Feeding Assistance

Meal Preparation

Toileting Assistance

Bathing (standby help)

Bathing (full help)

Grooming (setup)

Grooming (full assist)

Dressing (lay out clothes)

Dressing (full assist)

Assistance Needed (Notes)

Incontinence

N/A

Bladder Incontinence

Bowel Incontinence

Foley

Incontinence (Notes)

Special Dietary Needs

N/A

Pureed Diet

Mechanical Soft Diet

Vegetarian

Gluten Free

Dairy Free

Special Dietary Needs (Notes)

Housekeeping & Laundry

Independent

Can perform basic tasks but sometimes needs help

Very light tasks only - can't maintain acceptable level of cleanliness

All tasks must be performed by staff

Housekeeping & Laundry (Notes)

Health Needs

Let's remember we all have bad days, but no one wants to be judged by them. When completing the following questions please give the response based on a normal day in your Loved One's life.

Primary Diagnosis

Check all conditions that apply:

Check all treatments that are currently being administered:

Dialysis

Supplemental Oxygen

Physical Therapy

Occupational Therapy

Speech Therapy

Medication Management

Personality/Behavior

Quiet/Pleasant

Social

Activities/Hobbies

Combative

Refuses Care

Verbally Abusive

Wander Risk

ADD NOTES

Personality/Behavior (Notes)

Cognition

Alert/No Dementia

Some Memory Loss

Alzheimer's and/or Dementia

ADD NOTES

Cognition (Notes)

Diabetic Needs

N/A

Glucose Checks

Managed by Diet

Oral Medications

Standard Insulin

Sliding Scale Insulin

ADD NOTES

Diabetic Needs (Notes)

Diabetic Assistance Needs

N/A

Independent

Needs Reminders

Needs Nurse Assistance

ADD NOTES

Diabetic Assistance Needs (Notes)

Sleep Disturbance

No problems with sleep

Occasionally has problems with sleep

Frequently has problems with sleep

ADD NOTES

Additional Care Needs

Awake Caregiver at night

Feeding Tube

Tracheotomy Care

Wound Care

Oxygen

ADD NOTES

Medication Management

Independent

Needs dosages prepared. Can self administer.

Needs assistance with storage and prep with reminders.

Requires complete supervision and administration.

ADD NOTES

Sleep Disturbance (Notes)

Additional Care Needs (Notes)

Med Management (Notes)

Care Providers

Provider Name

Type of Provider

Phone Number

Fax Number

Add another provider?

Yes

Provider Name

Type of Provider

Phone Number

Fax Number

Getting to know your loved one

This is the really important piece of the puzzle for us. We have learned about care requirement, finances, and some other stuff. But for us, we want to know WHO your loved one is. This also helps us match your loved one's personality with the appropriate residents and staff at different homes.

Hometown

Past Profession

Religion

What activities would be enjoyed?

Additional Hobbies/Interests

How did you hear about Harmony Senior Living?

Let us know how you heard about Harmony!

Referral Source

Please, allow us to thank them by leaving their name.

CONSENT

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