Bienvenidos a Social Center Adult Day Care
En
Social Center Adult Day Care
nos encargamos de que tú o tu familiar encuentren el centro de cuidado para adultos
más cercano a su zona
.
✍Paso 1:
Ingresa tu información para comenzar
📅 Paso 2:
Elige la fecha de tu cita en el calendario
GENERAL INFORMATION
Responsible person's name
Contact phone
*
Email
Older adult's full name
*
Address
*
Mailing address
City
Region/province/state
Country
Country
ZIP code
Date of birth
*
Sex
Female
Male
Prefer not to answer
Select your current marital status:
Single
Married / Stable union
Widowed
Divorced
Monthly income
Medical diagnosis
Relationship to the older adult
Son/Daughter
Grandchild
Spouse
I am the older adult
Other
a) What age range is the older adult in?
*
Under 60 years old
60 – 64 years old
65 – 74 years old
75 – 84 years old
85 years or older
b) Select the option that describes the older adult's health coverage
*
Medicaid
Medicare
Private insurance
None
Not sure
c) Primary health condition of the older adult
Alzheimer's / Dementia
Parkinson's
Limited mobility / Requires daily assistance
None (Looking for companionship/activities)
Other medical condition
Others:
d) In which of these areas does the older adult need daily support?
Mobility (walking, transferring)
Medication (reminding or administering)
Personal hygiene (bathing, grooming)
Nutrition (eating, preparing meals)
None
(Selecciona todas las que correspondan)
e) How many days per week would you be interested in attending the center?
1-2 days
3-4 days
5 days (Monday to Friday)
f) Would you like to schedule a free visit to our center?
Yes, I want to book a visit
Not for now
g) Do you wish to attend with a guest?
Yes
No
Guest's First and Last Name
Submit