Inquiry Form - Graceful Hearts Senior Living

Date *

Person taking inquiry

How did you hear about us? *

Contact Person *

Best Phone # *

Applicant address *

Email

What’s the best way to communicate- text, email, phone?

Potential Resident *

Person Calling *

Relationship (sister, daughter, brother)

Walk me through a typical day for your family member- The daily activities and take notes as questions arise.

What brought you in here today? Was there a fall or troubling situation?

What is your timeframe to make a change? *

Who is involved in this decision? *

Did you have a budget figure in mind?

Did you have any financial concerns?

In our community, we care about each resident’s entire wellbeing. Do you mind if I ask You a few additional questions?

What fun things does he/she like to do?

What does he/she like to eat?

Who are the important people in his/her life?

What did he/she do before retirement?

How does he/she feel about making this change?

Are there any other important things in his/her life that you want to share?

What is most important to YOU in making this decision?

What is your goal for your family member’s care?

Next Step in Process/Date: Inquriry/Tour/Deposit/Move In

Tour
Assessment
Deposit
Home Visit
Move In

Once Offering the next step if not accepted ask what barriers they may have to completing a next step in the process? Overcome the barrier with a solution and ask again, for the next step.

Additional Comments: