Contact Us
 
Please call Hadva Glickman at (818) 716-8785
Or email at BestSeniorPlacement@socal.rr.com
You can print and complete the form below or just make sure you have this information when contacting us:

Your Contact Information
Your First Name:
Your Last Name:
Your Address:
City:
State:
Home Phone Number (please provide at least one phone contact number):
Business Number:
Cell Phone:
Fax:
Email Address:
What is your relationship to the senior?:
Senior's Information
Senior's First Name:
Senior's Last name:
Sex:
female male
Age:
Date of Birth:
If this is a couple Name of Second Person:
Sex:
female male
Age:
Date of Birth:
Presently living where?
Home With Relatives Facility
If presently living at facility, please indicate name:
Diagnosis:
Heart disease Alzheimer’s Disease 
Stroke  Parkinson’s Disease
Emphysema Mental Illness
Dementia Diabetic
TIA’s  Depression
Congestive Heart Disease
Macular Degeneration   
Other?
Assistance needed:
Bathing Walking 
Dressing  Injections
Medications Catheter 
Incontinence Colostomy  
Toileting  Feeding 
Fill in the following if applicable:
Self Sufficient Oxygen     
Forgetful Wanderer 
Confused  Tube Feeding 
Cane IV 
Walker Aphasia
Wheelchair  Smoker   
Electric cart Pets     
Bedridden       
Blind      
Partially Sighted    
Deaf      
Hard of Hearing   
Religious/Cultural Preference? (Optional)
Additional Information
What type of Facilities are you looking for:
Type of Room Desired?:
What is the monthly budget:
Location:
City preferred:
How soon do you need placement?:
How did you hear about
Executive Information and Referral?

Other?
May a facility contact you for questions?
yes no
May a facility send you a brochure?
yes no
To best serve you, please indicate any facilities you have seen or contacted to avoid duplication:
Additional Information or Comments:


BestSeniorPlacement@socal.rr.com


   
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