Online Assessment/Intake – Complete Elder Solutions

Payment

Online Assessment: $299.99

Name on Card*

Credit Card*

Credit Card

Total

Contact Information

Name*

Date*

Email Address*

Phone Number*

Address*

Address

Are these services for yourself or a loved one?*

Myself

Loved one

Please indicate which service(s) you are interested in:*

Care Management

Medicaid Waiver (Community or Assisted Living)

Medicaid ICP (Nursing Home)

VA Benefits

POA (Power of Attorney)

Health Care Surrogate

(ALF) Assisted Living Facility and (SNF) Skilled Nursing Facility

Assets Protection

QIT (Qualified Income Trust)

Notes and Comments

Referral Source (Organization, Name, Phone Number)

Applicant Information

Applicant Name*

DOB*

Spouse Name (if applicable)

Spouse DOB

What is your primary concern?*

Cognition

Short-Term Memory*

Poor

Good

Short-Term Memory Notes

Long-Term Memory*

Poor

Good

Long-Term Memory Notes

Activities of Daily Living (ADL)

Does the applicant require assistance with any of the following?*

Dressing

Bathing

Meal Prep

Medication Management

Housekeeping

Driving

OtherOther

Check all that apply

Does the applicant experience any issues with toileting?*

Yes

NotesNotes

Check all that apply

Does the applicant require assistance Getting Around?*

With Cane

Client

$.00

Client

$.00

Spouse

$.00

Spouse

$.00

Comments

Have you transferred more than $2,000 in the past five (5) years?

Yes

Transfer Comments

Have you gifted more than $2,000 in the past five (5) years?

Yes

Gifted Comments

Have you closed any bank accounts in the past five (5) years?

Yes

Account Comments

Have you sold or transferred any property in the past five (5) years?

Yes

Sale/Transfer Comments

Do you own more than one property?

Yes

Ownership Comments

Do you own more than one vehicle?

Yes

Do you have any life insurance policies?

Yes

Life-Insurance Comments

Online Assesment

Please complete the online assessment as required by Complete Elder Solutions. Be sure that the information you provide is accurate and complete to the best of your knowledge. All the information submitted shall be encrypted and strictly used only in compliance with Florida Law, Guidelines and Ordinances.

Thank You

How did you hear about Complete Elder Solutions?*

Friend

Nursing Home

Social Media

Internet

OtherOther

Do you have a Healthcare Surrogate?*

Yes

Surrogate Comments

Will Comments

What is the short/long-term care plan?

For Example: “Home-Care, Assisted Living or Nursing Home”

By submitting this online assessment, you hereby acknowledge that this isn’t an application for public benefits but a tool to determine eligibility. All applications are required to be approved by the State of Florida

reCAPTCHA

LOOKING FOR SERVICES FOR A LOVED ONE?

Payment

Contact Information

Applicant Information

Cognition

Activities of Daily Living (ADL)

Financial Pre-Screening – this is only required for public or Medicare benefits

Social Security (Gross)

Pension/Retirement (Gross)

Other Income (Gross)

Annuities

IRA (Individual Retirement Account)

Checking

Savings

CD’s

401K

Stocks/Bonds

Money Market

Trust Account

Special Needs Trust Acct

Life Insurance Policy

Medical Expenses

Personal Aid

Online Assesment