Contact Us Please contact us by using this form or you can Phone, Mail or Email us. Senior Living Options, Inc. Personal Mail Box: 331 12042 SE Sunnyside Road Clackamas, OR 97015 Doug Rusch: 503-528-6729 drusch@seniorlivingoptionsinc.com Fax: 866-531-8625 * - Required Fields Contact Information * First Name: * Last Name: Address Street City: State: - select - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip:     Home Phone: Cell Phone: * Email: Best Time to Reach You: - select - 7am to 11am 12pm 1pm to 7pm Relation to Client: - select - Spouse Son In Law Son Sibling Power of Attorney Uncle Aunt Niece Nephew Myself Lawyer Healthcare Professional Grandchild Friend Daughter Daughter In Law Other How did you hear about us? - select - Friend Family Member Internet search Physician Healthcare Professional Event or seminar Church Print Advertisement Other   Client Information Client First Name: Client Last Name: Address Street City: State: - select - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip:     Monthly Budget: Minimum Maximum - select - under $2,000 $2,500 $3,000 $4,000 Over $4,000 - select - under $2,000 $2,500 $3,000 $4,000 $5,000 Over $5,000 Clients Age: Clients Weight: Clients Height: Medicaid: - select - Yes No Other Current Living Situation: - select - Adult Family Home Assisted Living Facility Home (live alone) Home (home health services) Live With Family Hospital Memory Care Nursing Home Residential Care Retirement Living Memory Loss: - select - Alzheimer's Dementia No Memory Loss Occasional Loss Frequent Loss Wandering Exit Seeking Walking Ability: - select - Independent Cane Walker Wheelchair No Mobility Stretcher When are you looking to make the move? - select - Immediately 1-2 weeks 3-4 weeks 1-2 months 3-4 months Over 5 months   Assistance Needed Full Assistance Some Assistance No Assistance Medications Meal Preparation Dressing Hair Care/Shaving Bathing or Showering Toileting Eating Transfers and Mobility   Homes or Community Preferences Type Needed: Apatrment Size: Amenities & Services: Assisted Living Studio Community Outings Retirement Living Community One Bedroom Full Kitchen Nursing Home Two Bedroom Mini Kitchen Alzheimer's Memory Care   Pets Allowed Adult Family Bathroom: Resident Parking Not sure Private     Shared     Doesn't Matter     Other Information: Please add any additional questions or comments.

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