Senior Living Community Information Questionnaire Community Name*Number of Beds*Facility Type*Please select all that apply: Independent Living Assisted Living Short-Term Rehab Custodial Memory Care Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact InformationMemory Care DirectorName First Last PhoneEmail Administrator/Executive DirectorName First Last PhoneEmail Director of NursingName First Last PhoneEmail Marketing DirectorName First Last PhoneEmail Business Office ManagerName First Last PhoneEmail Social Work DirectorName First Last PhoneEmail Does your facility accept Medicaid?*YesNoDoes the facility have a required private pay period?*YesNoIf so, how long is their private pay period?1 Year2 YearOtherDo your residents have Advance Directives in place, or do they need them?*Yes, They have them in place or most have them in placeNo, They don’t have them in place or most don’t have them in placeWhat’s your process for helping families apply for Medicaid?*What’s your process for helping families apply for the Veteran’s benefit Aid and Attendance?*Many will say they just tell families what the normal facility cost is, and when the families can’t afford it they recommend the family apply for Medicaid and spend down. If this is the case, they really need an elder law attorney to help families do this just right. What attorneys or law firms do you refer to?*Would you consider referring to another qualified attorney?*If yes, let them know the experience you and the firm have and how easy it is to refer to you so they can relax knowing the family is in good hands.YesNoDo most of your residents/patients use a personal guardian or do you use legal guardians?*Personal GuardianLegal GuardianNoneDo your residents have Wills & POAs in place?*Yes, they have them in place or most have them in place.No, they don’t have them in place or most don’t have them in place.OtherWhy should families choose your facility? What makes your facility different and better?*Your Contact InformationYour Name* First Last Your Email* Your Phone*EmailThis field is for validation purposes and should be left unchanged.
