The Neighborhood House - Assessment
Looking for the proper care for your loved one can be overwhelming. And expensive. We are here to help. In certain circumstances, financial assistance may be available. By answering a few questions, we can assess if the Neighborhood House is the right place for your loved one - physically, emotionally and financially. 
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Email *
Name of person completing form (optional)
About your loved one:
Tell us a little bit about the person you are researching for.
Who is this for? *
How old is this person? *
What is your loved one's current living situation? *
Does your loved one drive? *
Why are you considering moving your loved one? (check all that apply) *
Required
Which of the following activities, if any, does your loved one have difficulty with? (check all that apply) *
Required
How is your loved one's mobility? *
How would you describe your loved one's memory? *
Does your loved one have any behavioral issues? If so, please explain.
Is your loved one a US veteran or a spouse of a veteran (in certain cases, additional funds may be available to help pay for their care)? *
If your loved one is a veteran or the spouse of a veteran, what year(s) did they serve?
FINANCES (optional, however, this information is needed to determine if financial aid is available). Tell us about any financial resources that may be available to help pay for your loved one's care. Check all that apply.
MONTHLY INCOME (optional, however, this information is needed to determine if financial aid is available). How much income does your loved one receive each month?
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What kind of health insurance does your loved one have? (check all that apply) *
Required
Is there anything else you think we should know about your loved one, including additional health issues (i.e. on oxygen, is incontinent, has a cancer diagnosis? (optional)
Based on the information you provided so far, would you like us to contact you to advise if we think your loved one may qualify for financial assistance at the Neighborhood House? *
If you answered YES to the previous question, please let us know how you would like to be contacted. Please provide an email address, phone number, or other preferred method of contact (we do not share your contact information with anyone else).
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