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ECURE ADULT FAMILY ENVIRONMENT, INC.

Secure Adult Family Environment, Inc.

Phone# 727-538-4120

Fax # 727-538-4201
13575 58th Street North #127

Clearwater, Florida, 33760

* First name (required):

* Last name (required):
* E-mail address (required):

Phone number:
* Message (required):

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Take time now to complete the Monitoring needs survey and find quality help.

(Please print-fax or copy and paste and send in the email section- have this completed document when you call so that all your questions may be addressed.)

Contact Information:

Why We Worry

Please provide the following information for the person completing the needs survey and requesting results.

Salutation:
First Name:	**
Last Name:	**
Email:	**
Zip Code:	**
Primary Phone:	x
Secondary Phone:	x
Best time to call:

From the list of choices below, select those that describe your needs:

(Select all that apply)

Home Services and/or Adult Day Care Services that will allow you (or the person you are concerned about) to continue to live safely at home (e.g. non-medical home monitoring)

Both Eldercare Residence and In-Home Options (provide me with options for both senior housing and in-home monitoring)

in home use of Medical Equipment and/or Eldercare Products (e.g. home medical products, durable medical equipment, ambulatory aids, hearing aids, personal medical alarms)

Advisory and/or Consultative Services (e.g. annual evaluation or monthly evaluation, in-home planning, long term care planning)

Business/Employment. I am interested in employment opportunities, franchise or a business relationship with Secure Adult Family Environment, Inc.

WELL CALL. I am interested in having a daily, automated call placed to my loved one/family member, to be assured of their safety and ability to respond.

Please provide the desired location for the service(s) or product(s) to be provided:

City:	**	State:
Zip:

The type of residence where care is to be provided:
Please select all that apply

Resident's Home	Adult Day Care Facility
Independent Living / Senior Community	Group Home / Residential Care Home
Assisted Living Facility	Continuing Care Retirement Community
Skilled Nursing Facility / Nursing Home

Services that you believe are required for the care recipient:
Please select all that apply

Adult Day Care/Respite Care	Transition Services (e.g., home sale, relocation to senior development, or assisted living facility)

Companion Services	Transportation Non-Medical (e.g. Errands, Shopping)

Geriatric Evaluation	Transportation Medical (Non-Emergency)

Home / Safety Monitoring	Handyman/Odd Job/Misc. Household Repairs

Homecare (Non-Medical)	Homemaker/ House Cleaning

Do you need or desire any additional services?

What funding source(s) will be the primary payer for the services or products?
(Please select one)

Private pay(preferred)	Credit card
Debit card
Combination (Private Pay, Medicare, Insurance,{help with filing re-embursement forms for Ins./ Medicare, if available)

Family Needs Survey

Self	In-Law
Spouse	Sibling
Parent	Other Relative
Child	Friend
Grandparent

Please provide the following information about the care recipient.

Gender:

Age:

When would you like services to begin?
(Please select one)

As soon as possible	Within 4 Weeks
Within 2 Weeks	Within 8 Weeks

What frequency of service do you think the recipient requires?

(Please select one)

Once every two weeks	Once per week
Twice per week	Three times
Every day	Annual

Which best describes the recipient's current living arrangement?
(Please select one)

At home and living independently	Skilled nursing facility / nursing home
At home with some services in place	Hospital or rehabilitation facility
Assisted living facility	Living with spouse/companion

Please describe the recipient's feelings about monitoring visits?

Very Receptive	Resistant to Help
Somewhat Receptive	Unknown

OPTIONAL: Secure Adult Family Environment, Inc. has information kits, and other material that may be helpful to you as you progress through the monitoring system. If you are interested in receiving such information, please provide the appropriate mailing information.

First Name:
Last Name:
Street Address:
City:
State:
Zip:

ebar-av@SafeSeniorsAtHome.com

All pages and attached documentation have copyright pending and are the exclusive property of Secure Adult Family Environment, Inc. They may not be utilized, copied, or duplicated without express written authorization. Certain pictures and logos are in the public domain. The remainder have patent pending or are used with special permission by owners and publishers.

Secure Adult Family Environment, Inc.

We're working to keep our Seniors, the Frail and Disabled "Safe and Secure "in their homes for as long as possible .