Questionnaire "*" indicates required fields Step 1 of 7 14% Welcome to Our Care Assessment Our Self Assessment was created to provide the comfort you need in knowing that we can help you and your loved one in their time of need. This personalized tool is designed to help you identify the ideal level of senior living care tailored to you or your loved one's unique needs and preferences. It takes just 4 minutes to make sure your mom, dad or loved one gets the right level of care and to answer your most pressing questions. Who is this guide intended for ?* Mom Dad Spouse Siblings Grandma Grandpa Self How independent is your mom when moving around the home and elsewhere?* Very mobile and need no assistance. Relies on assistive devices for stability to get around (cane/walker/wheelchair), but is generally independent with limited assistance getting in and out of bed or navigating stairs. Need moderate assistance to get in and out of bed, sit in a chair or get up, and navigate stairs. She need extensive assistance getting out of bed or around due to poor vision/hearing, lack of strength, or lack of motivation. She need mobility assistance regularly because of confusion or forgetfulness, regardless of physical ability. How independent is your dad when moving around the home and elsewhere?* Very mobile and need no assistance. Relies on assistive devices for stability to get around (cane/walker/wheelchair), but is generally independent with limited assistance getting in and out of bed or navigating stairs. Need moderate assistance to get in and out of bed, sit in a chair or get up, and navigate stairs. He need extensive assistance getting out of bed or around due to poor vision/hearing, lack of strength, or lack of motivation. He need mobility assistance regularly because of confusion or forgetfulness, regardless of physical ability. How independent is your spouse when moving around the home and elsewhere?* Very mobile and need no assistance. Relies on assistive devices for stability to get around (cane/walker/wheelchair), but is generally independent with limited assistance getting in and out of bed or navigating stairs. Need moderate assistance to get in and out of bed, sit in a chair or get up, and navigate stairs. He/she need extensive assistance getting out of bed or around due to poor vision/hearing, lack of strength, or lack of motivation. He/she need mobility assistance regularly because of confusion or forgetfulness, regardless of physical ability. How independent is your sibling when moving around the home and elsewhere?* Very mobile and need no assistance. Relies on assistive devices for stability to get around (cane/walker/wheelchair), but is generally independent with limited assistance getting in and out of bed or navigating stairs. Need moderate assistance to get in and out of bed, sit in a chair or get up, and navigate stairs. He/she need extensive assistance getting out of bed or around due to poor vision/hearing, lack of strength, or lack of motivation. He/she need mobility assistance regularly because of confusion or forgetfulness, regardless of physical ability. How independent is your grandma when moving around the home and elsewhere?* Very mobile and need no assistance. Relies on assistive devices for stability to get around (cane/walker/wheelchair), but is generally independent with limited assistance getting in and out of bed or navigating stairs. Need moderate assistance to get in and out of bed, sit in a chair or get up, and navigate stairs. She need extensive assistance getting out of bed or around due to poor vision/hearing, lack of strength, or lack of motivation. She need mobility assistance regularly because of confusion or forgetfulness, regardless of physical ability. How independent is your grandpa when moving around the home and elsewhere?* Very mobile and need no assistance. Relies on assistive devices for stability to get around (cane/walker/wheelchair), but is generally independent with limited assistance getting in and out of bed or navigating stairs. Need moderate assistance to get in and out of bed, sit in a chair or get up, and navigate stairs. He need extensive assistance getting out of bed or around due to poor vision/hearing, lack of strength, or lack of motivation. He need mobility assistance regularly because of confusion or forgetfulness, regardless of physical ability. How independent are your self when moving around the home and elsewhere?* Very mobile and need no assistance. Relies on assistive devices for stability to get around (cane/walker/wheelchair), but is generally independent with limited assistance getting in and out of bed or navigating stairs. Need moderate assistance to get in and out of bed, sit in a chair or get up, and navigate stairs. You need extensive assistance getting out of bed or around due to poor vision/hearing, lack of strength, or lack of motivation. You need mobility assistance regularly because of confusion or forgetfulness, regardless of physical ability. When it comes to transportation, does your mom:* Own a car and can drive safely as needed. Need occasional assistance with certain tasks or trips around town. Rely on assistance for all transportation need. Should not drive because of confusion, getting lost, forgetfulness, etc. When it comes to transportation, does your dad:* Own a car and can drive safely as needed. Need occasional assistance with certain tasks or trips around town. Rely on assistance for all transportation need. Should not drive because of confusion, getting lost, forgetfulness, etc. When it comes to transportation, does your spouse:* Own a car and can drive safely as needed. Need occasional assistance with certain tasks or trips around town. Rely on assistance for all transportation need. Should not drive because of confusion, getting lost, forgetfulness, etc. When it comes to transportation, does your sibling:* Own a car and can drive safely as needed. Need occasional assistance with certain tasks or trips around town. Rely on assistance for all transportation need. Should not drive because of confusion, getting lost, forgetfulness, etc. When it comes to transportation, does your grandma:* Own a car and can drive safely as needed. Need occasional assistance with certain tasks or trips around town. Rely on assistance for all transportation need. Should not drive because of confusion, getting lost, forgetfulness, etc. When it comes to transportation, does your grandpa:* Own a car and can drive safely as needed. Need occasional assistance with certain tasks or trips around town. Rely on assistance for all transportation need. Should not drive because of confusion, getting lost, forgetfulness, etc. When it comes to transportation, does your self:* Own a car and can drive safely as needed. Need occasional assistance with certain tasks or trips around town. Rely on assistance for all transportation need. Should not drive because of confusion, getting lost, forgetfulness, etc. How independent is your mom when it comes to making meals and eating them?* Able to prepare own meals and eat independently. Need meals prepared, and prefers to socially interact with others when dining. Need meals prepared and some reminders/queuing with dining. Need meals prepared and daily physical assistance with dining. Always need reminders and assistance with dining. How independent is your dad when it comes to making meals and eating them?* Able to prepare own meals and eat independently. Need meals prepared, and prefers to socially interact with others when dining. Need meals prepared and some reminders/queuing with dining. Need meals prepared and daily physical assistance with dining. Always need reminders and assistance with dining. How independent is your spouse when it comes to making meals and eating them?* Able to prepare own meals and eat independently. Need meals prepared, and prefers to socially interact with others when dining. Need meals prepared and some reminders/queuing with dining. Need meals prepared and daily physical assistance with dining. Always need reminders and assistance with dining. How independent is your sibling when it comes to making meals and eating them?* Able to prepare own meals and eat independently. Need meals prepared, and prefers to socially interact with others when dining. Need meals prepared and some reminders/queuing with dining. Need meals prepared and daily physical assistance with dining. Always need reminders and assistance with dining. How independent is your grandma when it comes to making meals and eating them?* Able to prepare own meals and eat independently. Need meals prepared, and prefers to socially interact with others when dining. Need meals prepared and some reminders/queuing with dining. Need meals prepared and daily physical assistance with dining. Always need reminders and assistance with dining. How independent is your grandpa when it comes to making meals and eating them?* Able to prepare own meals and eat independently. Need meals prepared, and prefers to socially interact with others when dining. Need meals prepared and some reminders/queuing with dining. Need meals prepared and daily physical assistance with dining. Always need reminders and assistance with dining. How independent are your self when it comes to making meals and eating them?* Able to prepare own meals and eat independently. Need meals prepared, and prefers to socially interact with others when dining. Need meals prepared and some reminders/queuing with dining. Need meals prepared and daily physical assistance with dining. Always need reminders and assistance with dining. How independent is your mom when it comes to personal hygiene tasks?* Independent in all personal care. Occasionally need reminders or light assistance, but is usually very aware and in control of personal hygiene. Regularly need reminders or need help performing some tasks, such as getting into a bathtub/shower, hairdressing, or shaving. Generally can manage hygiene but need assistance or reminders with personal care due to confusion or lack of motivation. Need help with all or most personal hygiene tasks. How independent is your dad when it comes to personal hygiene tasks?* Independent in all personal care. Occasionally need reminders or light assistance, but is usually very aware and in control of personal hygiene. Regularly need reminders or need help performing some tasks, such as getting into a bathtub/shower, hairdressing, or shaving. Generally can manage hygiene but need assistance or reminders with personal care due to confusion or lack of motivation. Need help with all or most personal hygiene tasks. How independent is your spouse when it comes to personal hygiene tasks?* Independent in all personal care. Occasionally need reminders or light assistance, but is usually very aware and in control of personal hygiene. Regularly need reminders or need help performing some tasks, such as getting into a bathtub/shower, hairdressing, or shaving. Generally can manage hygiene but need assistance or reminders with personal care due to confusion or lack of motivation. Need help with all or most personal hygiene tasks. How independent is your sibling when it comes to personal hygiene tasks?* Independent in all personal care. Occasionally need reminders or light assistance, but is usually very aware and in control of personal hygiene. Regularly need reminders or need help performing some tasks, such as getting into a bathtub/shower, hairdressing, or shaving. Generally can manage hygiene but need assistance or reminders with personal care due to confusion or lack of motivation. Need help with all or most personal hygiene tasks. How independent is your grandma when it comes to personal hygiene tasks?* Independent in all personal care. Occasionally need reminders or light assistance, but is usually very aware and in control of personal hygiene. Regularly need reminders or need help performing some tasks, such as getting into a bathtub/shower, hairdressing, or shaving. Generally can manage hygiene but need assistance or reminders with personal care due to confusion or lack of motivation. Need help with all or most personal hygiene tasks. How independent is your grandpa when it comes to personal hygiene tasks?* Independent in all personal care. Occasionally need reminders or light assistance, but is usually very aware and in control of personal hygiene. Regularly need reminders or need help performing some tasks, such as getting into a bathtub/shower, hairdressing, or shaving. Generally can manage hygiene but need assistance or reminders with personal care due to confusion or lack of motivation. Need help with all or most personal hygiene tasks. How independent are your self when it comes to personal hygiene tasks?* Independent in all personal care. Occasionally need reminders or light assistance, but is usually very aware and in control of personal hygiene. Regularly need reminders or need help performing some tasks, such as getting into a bathtub/shower, hairdressing, or shaving. Generally can manage hygiene but need assistance or reminders with personal care due to confusion or lack of motivation. Need help with all or most personal hygiene tasks. How independent is your mom when it comes to housekeeping tasks?* Independent in all housekeeping duties. Need help to perform some housekeeping tasks, such as thorough cleaning. Need help with all housekeeping tasks due to physical limitations. Unable to perform any housekeeping tasks due to confusion or forgetfulness. How independent is your dad when it comes to housekeeping tasks?* Independent in all housekeeping duties. Need help to perform some housekeeping tasks, such as thorough cleaning. Need help with all housekeeping tasks due to physical limitations. Unable to perform any housekeeping tasks due to confusion or forgetfulness. How independent is your spouse when it comes to housekeeping tasks?* Independent in all housekeeping duties. Need help to perform some housekeeping tasks, such as thorough cleaning. Need help with all housekeeping tasks due to physical limitations. Unable to perform any housekeeping tasks due to confusion or forgetfulness. How independent are your self with getting dressed?* Able to dress self independently at all times. Able to dress self but sometimes need help with certain dressing activities such as tying shoelaces, zippers, medical appliances, or garments. Can dress oneself but always need help with tasks, such as shoelaces, zippers, medical appliances, or garments. Always need assistance with dressing and undressing. How independent is your sibling when it comes to housekeeping tasks?* Independent in all housekeeping duties. Need help to perform some housekeeping tasks, such as thorough cleaning. Need help with all housekeeping tasks due to physical limitations. Unable to perform any housekeeping tasks due to confusion or forgetfulness. How independent is your grandma when it comes to housekeeping tasks?* Independent in all housekeeping duties. Need help to perform some housekeeping tasks, such as thorough cleaning. Need help with all housekeeping tasks due to physical limitations. Unable to perform any housekeeping tasks due to confusion or forgetfulness. How independent is your grandpa when it comes to housekeeping tasks?* Independent in all housekeeping duties. Need help to perform some housekeeping tasks, such as thorough cleaning. Need help with all housekeeping tasks due to physical limitations. Unable to perform any housekeeping tasks due to confusion or forgetfulness. How independent are your self when it comes to housekeeping tasks?* Independent in all housekeeping duties. Need help to perform some housekeeping tasks, such as thorough cleaning. Need help with all housekeeping tasks due to physical limitations. Unable to perform any housekeeping tasks due to confusion or forgetfulness. How independent is your mom with getting dressed?* Able to dress self independently at all times. Able to dress self but sometimes need help with certain dressing activities such as tying shoelaces, zippers, medical appliances, or garments. Can dress oneself but always need help with tasks, such as shoelaces, zippers, medical appliances, or garments. Always need assistance with dressing and undressing. How independent is your dad with getting dressed?* Able to dress self independently at all times. Able to dress self but sometimes need help with certain dressing activities such as tying shoelaces, zippers, medical appliances, or garments. Can dress oneself but always need help with tasks, such as shoelaces, zippers, medical appliances, or garments. Always need assistance with dressing and undressing. How independent is your spouse with getting dressed?* Able to dress self independently at all times. Able to dress self but sometimes need help with certain dressing activities such as tying shoelaces, zippers, medical appliances, or garments. Can dress oneself but always need help with tasks, such as shoelaces, zippers, medical appliances, or garments. Always need assistance with dressing and undressing. How independent is your sibling with getting dressed?* Able to dress self independently at all times. Able to dress self but sometimes need help with certain dressing activities such as tying shoelaces, zippers, medical appliances, or garments. Can dress oneself but always need help with tasks, such as shoelaces, zippers, medical appliances, or garments. Always need assistance with dressing and undressing. How independent is your grandma with getting dressed?* Able to dress self independently at all times. Able to dress self but sometimes need help with certain dressing activities such as tying shoelaces, zippers, medical appliances, or garments. Can dress oneself but always need help with tasks, such as shoelaces, zippers, medical appliances, or garments. Always need assistance with dressing and undressing. How independent is your grandpa with getting dressed?* Able to dress self independently at all times. Able to dress self but sometimes need help with certain dressing activities such as tying shoelaces, zippers, medical appliances, or garments. Can dress oneself but always need help with tasks, such as shoelaces, zippers, medical appliances, or garments. Always need assistance with dressing and undressing. How independent is your mom in managing and administering medications?* Able to manage and administer own medications. Able to self-administer medications but sometimes need reminding or monitoring. Uses a medication administration system that provides reminders and monitoring. Need daily assistance and reminders to take medications. Medications must be administered by qualified caregivers. How independent is your dad in managing and administering medications?* Able to manage and administer own medications. Able to self-administer medications but sometimes need reminding or monitoring. Uses a medication administration system that provides reminders and monitoring. Need daily assistance and reminders to take medications. Medications must be administered by qualified caregivers. How independent is your spouse in managing and administering medications?* Able to manage and administer own medications. Able to self-administer medications but sometimes need reminding or monitoring. Uses a medication administration system that provides reminders and monitoring. Need daily assistance and reminders to take medications. Medications must be administered by qualified caregivers. How independent is your sibling in managing and administering medications?* Able to manage and administer own medications. Able to self-administer medications but sometimes need reminding or monitoring. Uses a medication administration system that provides reminders and monitoring. Need daily assistance and reminders to take medications. Medications must be administered by qualified caregivers. How independent is your grandma in managing and administering medications?* Able to manage and administer own medications. Able to self-administer medications but sometimes need reminding or monitoring. Uses a medication administration system that provides reminders and monitoring. Need daily assistance and reminders to take medications. Medications must be administered by qualified caregivers. How independent is your grandpa in managing and administering medications?* Able to manage and administer own medications. Able to self-administer medications but sometimes need reminding or monitoring. Uses a medication administration system that provides reminders and monitoring. Need daily assistance and reminders to take medications. Medications must be administered by qualified caregivers. How independent are your self in managing and administering medications?* Able to manage and administer own medications. Able to self-administer medications but sometimes need reminding or monitoring. Uses a medication administration system that provides reminders and monitoring. Need daily assistance and reminders to take medications. Medications must be administered by qualified caregivers. How is your mom's memory and mental orientation?* Her memory is good, and she is able to make decisions, plan, and organize daily events. Has occasional problems with short-term or long-term memory and sometimes need assistance with recalling information. Occasionally forgets time, place, or people; need direction or guidance in getting from place to place; or has occasional confusion that causes anxiety, social withdrawal, or depression. Quite forgetful nowadays. Often forgets how to do things or has difficulty with regular confusion that can cause anxiety, social withdrawal, or depression. Certain stages of dementia or early stages of Alzheimer's require assistance with all activities of daily living. How is your dad's memory and mental orientation?* His memory is good, and he is able to make decisions, plan, and organize daily events. Has occasional problems with short-term or long-term memory and sometimes need assistance with recalling information. Occasionally forgets time, place, or people; need direction or guidance in getting from place to place; or has occasional confusion that causes anxiety, social withdrawal, or depression. Quite forgetful nowadays. Often forgets how to do things or has difficulty with regular confusion that can cause anxiety, social withdrawal, or depression. Certain stages of dementia or early stages of Alzheimer's require assistance with all activities of daily living. How is your spouse's memory and mental orientation?* His/her memory is good, and he/she is able to make decisions, plan, and organize daily events. Has occasional problems with short-term or long-term memory and sometimes need assistance with recalling information. Occasionally forgets time, place, or people; need direction or guidance in getting from place to place; or has occasional confusion that causes anxiety, social withdrawal, or depression. Quite forgetful nowadays. Often forgets how to do things or has difficulty with regular confusion that can cause anxiety, social withdrawal, or depression. Certain stages of dementia or early stages of Alzheimer's require assistance with all activities of daily living. How is your sibling's memory and mental orientation?* His/her memory is good, and he/she is able to make decisions, plan, and organize daily events. Has occasional problems with short-term or long-term memory and sometimes need assistance with recalling information. Occasionally forgets time, place, or people; need direction or guidance in getting from place to place; or has occasional confusion that causes anxiety, social withdrawal, or depression. Quite forgetful nowadays. Often forgets how to do things or has difficulty with regular confusion that can cause anxiety, social withdrawal, or depression. Certain stages of dementia or early stages of Alzheimer's require assistance with all activities of daily living. How is your grandma's memory and mental orientation?* Her memory is good, and she is able to make decisions, plan, and organize daily events. Has occasional problems with short-term or long-term memory and sometimes need assistance with recalling information. Occasionally forgets time, place, or people; need direction or guidance in getting from place to place; or has occasional confusion that causes anxiety, social withdrawal, or depression. Quite forgetful nowadays. Often forgets how to do things or has difficulty with regular confusion that can cause anxiety, social withdrawal, or depression. Certain stages of dementia or early stages of Alzheimer's require assistance with all activities of daily living. How is your grandpa's memory and mental orientation?* His memory is good, and he is able to make decisions, plan, and organize daily events. Has occasional problems with short-term or long-term memory and sometimes need assistance with recalling information. Occasionally forgets time, place, or people; need direction or guidance in getting from place to place; or has occasional confusion that causes anxiety, social withdrawal, or depression. Quite forgetful nowadays. Often forgets how to do things or has difficulty with regular confusion that can cause anxiety, social withdrawal, or depression. Certain stages of dementia or early stages of Alzheimer's require assistance with all activities of daily living. How are your self's memory and mental orientation?* Your memory is good, and able to make decisions, plan, and organize daily events. Has occasional problems with short-term or long-term memory and sometimes need assistance with recalling information. Occasionally forgets time, place, or people; need direction or guidance in getting from place to place; or has occasional confusion that causes anxiety, social withdrawal, or depression. Quite forgetful nowadays. Often forgets how to do things or has difficulty with regular confusion that can cause anxiety, social withdrawal, or depression. Certain stages of dementia or early stages of Alzheimer's require assistance with all activities of daily living. Name* First Last Email* Phone Number* OUR CONTACT Get In Touch We’re here to address your questions, concerns, or inquiries. Feel free to contact us through any of the following methods, and our dedicated team will be happy to assist you: 949-278-8332 ghhomes.alcosta@gmail.com *24/7 full support service Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *MessageSend Message