Family Contact Information

First name

Last name

Email

Phone

What is your relationship to the senior?

What is the best time to contact you?

Senior Information

Senior's Full Name

Age

Current Living Situation

City/State Preferred for Placement:

Is the senior currently in a hospital or rehab?

Care Needs

Primary health concerns or diagnoses:

Does the senior need help with bathing, dressing, or medications?

Mobility & Safety

Has the senior experienced recent falls?

Is wandering or memory loss a concern?

Are there safety concerns at home?

Financial & Timeline Information

Estimated Monthly Budget:

Will private pay, long-term care insurance, or VA benefits be used?

Desired Move Timeline:

Preferences

Preferred amenities or community features:

Does location near family matter?

Religious or cultural preferences:

Pet friendly needed?

Additional Notes

Is there anything else we should know about the senior?

Senior Living Family Intake Questionnaire

Thank you for reaching out. This questionnaire helps us better understand your loved one’s needs so we can guide you toward the best senior living options. All information is kept confidential.

Care decisions are personal. Our guidance is professional.

We help families navigate senior living decisions with compassion, clarity, experienced insight—always keeping safety, dignity, and quality of life at the center.

Schedule Your First Call

Andrea Donaldson, LNHA, CDP

Andrea brings compassionate, medically informed guidance to help families choose the right senior living option with clarity and confidence.

You don’t have to figure this out alone.

When a loved one needs more support, the options can feel overwhelming. Pathway Senior Living Advisors helps families slow down, understand the choices, and move forward with clarity.