Contact Us Let Us Find You The Right Home All fields are required First Name Last Name Email Phone When are you looking to relocate? List preferred City(s) and/or Town(s) What kind of facility are you looking for? What kind of facility are you looking for? Assisted Living Adult Family Home Skilled Nursing Facility Who are you completing this form for? Who are you completing this form for?SelfParentSpouseFamily MemberFriend Where is the individual currently located? Do they need assistance in/out of the chair/bed? Do they need assistance in/out of the chair/bed?YesNo Do they need someone to walk beside for safety? Do they need someone to walk beside for safety?YesNo In the last 90 days have they been admitted to...(Check all that apply) In the last 90 days have they been admitted to...(Check all that apply) Emergency Room Hospital Skilled Nursing Facility/Rehab No Admissions Do they need assistance with any of the following? (Check all that apply) Do they need assistance with any of the following? (Check all that apply) Bathing Dressing Use of Bathroom Managing Medication(s) Preparing Meals No Assistance Needed Tell us about their mobility Tell us about their mobilityUses a caneUses a walkerUses a wheelchairIs bed boundWalks independently Do they have any of the following conditions? (Check all that apply) Do they have any of the following conditions? (Check all that apply) Insulin-Dependent Diabetes (Self Managed) Insulin-Dependent Diabetes (Needs Assistance Managing) Non-Insulin Dependent Diabetes Dementia MS ALS Parkinson's Desease Recent Brain Injury or Stroke Spinal Cord Injury No Conditions to Report In the last 90 days have they experienced a fall? How many? Do they have any challenging behaviors? (Check all that apply) Do they have any challenging behaviors? (Check all that apply) Wanders Exit Seeking Awake at Night Uncooperative with Care Shouts or Calls Out Constantly Verbally Inappropriate or Abusive Hallucinations or Paranoia No Challenging Behaviors Other Any additional information you'd like to share: Send Elderly Placement Services 263 Cleomella Court Hemet, CA 92543 Phone: (619) 804-8518Email: elderlyplacementservices@gmail.com Contact Hours Monday 9:00AM – 6:00PM Tuesday 9:00AM – 6:00PM Wednesday 9:00AM – 6:00PM Thursday 9:00AM – 6:00PM Friday 9:00AM – 6:00PM Saturday 10:00AM – 2:00PM Sunday Closed