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Tour Request Form

Thank you for your interest in touring our care home! Please complete the form below so we can better understand your needs and schedule a tour.

Anchor 1: Tour Request Form

Client Information

First & Last Name*

Phone Number*

Email Address*

Preferred Tour Date & Time*

Family or Primary Contact Information (If Applicable)

First & Last Name

Phone Number

Care Needs

What type of care is being sought?*

General Assisted Living

Memory Care (e.g., Alzheimer’s/Dementia)

Respite Care

Hospice

Other

Does the client need assistance with any of the following? (Check all that apply) *

Mobility (e.g., walker, wheelchair)

Medication management

Personal care (e.g., bathing, dressing, toileting)

Cognitive support (e.g., Alzheimer’s, Dementia)

Meal assistance

Other

Does the client have any medical conditions or special needs?

Yes

Is the client currently receiving care from a facility or healthcare provider?

Yes

Fit for Facility

Does the client require any specialized equipment? (e.g., oxygen, feeding tube, catheter)

Yes

What are the client’s main goals for care?

Independent living with minimal support

Full-time assistance with daily activities

Specialized care (e.g., memory care, medical needs)

Social and recreational activities

Other

Does the client have any preferences regarding their living environment?

Private room

Shared room

Quiet environment

Pet-friendly

Other

Additional Information

How did you hear about our facility?

Referral

Online Search

Social Media

Other

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