2 About Your Loved OneCurrent Living Situation * Select current situation... Lives Alone Lives With Family Hospital Rehabilitation Facility Skilled Nursing Facility Assisted Living Residential Care / Group Home Memory Care Other
4 Daily Personal CareHow much supervision is generally needed? Select... Mostly Independent Occasional Reminders Regular Supervision Significant Daily Supervision Overnight Supervision 24-Hour Supervision Not Sure
6 Monthly BudgetApproximate Monthly Budget Select... Under $3,000 $3,000–$4,000 $4,000–$5,000 $5,000–$6,000 $6,000–$8,000 $8,000+ Not Sure / Need Guidance
Expected Payment Source Select... Private Pay Long-Term Care Insurance Veterans Benefits / Exploring Benefits Medicaid / Exploring Benefits Family Assistance Combination Not Sure
Additional Budget or Financial Considerations
7 Family Decision-MakingPrimary Decision Maker / Contact
Is the family generally in agreement about exploring placement? Select... Yes No Still Discussing We Would Like Capricorn's Help With the Conversation
Would you like help coordinating provider conversations or tours? Select... Yes — In Person Yes — Virtual Either Not Yet
7 Anything Else We Should Know?7 Family AuthorizationI authorize Capricorn Group Care to contact me regarding senior-care placement and transition support and to use the information I voluntarily provide to assist with placement navigation. I understand that, when appropriate and authorized, Capricorn may discuss relevant placement information with participating providers for the purpose of exploring potential placement options. I understand that Capricorn Group Care provides placement navigation and coordination and does not guarantee provider availability, acceptance, admission, pricing, or length of stay. I understand that receiving providers conduct their own assessments and independently determine their capabilities, eligibility requirements, pricing, availability, and admission decisions.
Type your full name as your signature *
Please do not submit highly sensitive medical records, diagnosis details, medication lists, insurance documents, or other protected health information through this general form unless specifically requested through our secure intake portal. A Capricorn care coordinator will contact you to securely complete additional healthcare documentation if needed.
