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Aging-in-Place Readiness Check
This short form helps us prepare for your consultation so we can give you the most helpful guidance possible.
Section 1 - Basic Information
Your Name
Last Name
Phone
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Anguilla
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
American Samoa
Ascension Island
Åland Islands
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bonaire, Sint Eustatius and Saba
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei Darussalam
Burkina Faso
Bulgaria
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (DRC)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Côte d'Ivoire
Czechia
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Faroe Islands
Falkland Islands
Fiji
Finland
France
French Guiana
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Guernsey
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
North Korea
North Macedonia
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Samoa
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
San Marino
São Tomé and Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria
Tajikistan
Taiwan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
U.S. Virgin Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Confirm
Confirm
Email
Your relationship to the senior
Daughter / Son
Spouse
Sibling
Other
Senior's age
Senior's city
Section 2 - What's Happening
Where is the senior currently living?
Alone at home
With family
Independent living
Assisted living
Other
What prompted you to reach out now?
What is your biggest concern right now?
Have there been any of the following in the last 6 months?
Fall
ER visit
Hospital stay
Medication confusion
Noticeable memory decline
Increased isolation
None of the above
Section 3 - Looking Ahead
If nothing changes in the next 6 months, what worries you most?
How sustainable is the current situation for you personally?
Completely manageable
Stressful but manageable
Overwhelming
Unsustainable
What would “peace of mind” look like for you?
Section 4 - Next steps
Are you the primary decision-maker?
Yes
No
If no, please explain
Are you currenlty speaking with other providers?
Yes
No
If we're a good fit, how soon would you want support in place?
Immediately
Within a few weeks
Just exploring
Anything else we should know before our call?
Submit
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(844) 224-3578
1010 S. 336th Street, Suite 106 Federal Way, WA 98003
info@bridging.care