This is an example of a form which could gather quite specific information. Hover over the fields to see the individual hints.

Intake Form  

Your First Name Your Last Name
Your Street Address
Your City
Your State Your Zip Code
Your Phone Number Best Time to Call
Your e-mail
Who are you calling For? Relationship to You?
Why can't this person live alone any longer?
Primary Diagnosis Age?
Do you have Power of Attorney? What price range are you looking for?
Does this person have veterans benefits? Do you prefer a larger community or a small board and care?
Are you working with anyone else? Who?
Have you toured any facilities?
Is there anything else we need to know?

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