Pinky Promise Creators Client Questionnaire

1. Why are you seeking assisted living services?
__________________________________________________________________

2. What does independence mean to you?
__________________________________________________________________

3. How do you prefer to communicate with staff and other residents?
(a) In-person
(b) Phone
(c) Written messages
(d) Other: _______________________

4. How would you rate your physical mobility?
(a) Fully independent
(b) Occasionally requires assistance
(c) Frequently requires assistance
(d) Use of mobility devices (wheelchair, walker, etc.)

5. What is your preferred daily routine?
__________________________________________________________________

6. How important is social interaction to you?
(a) Very important
(b) Somewhat important
(c) Not important

7. What challenges do you currently face in daily living?
__________________________________________________________________

8. How do you prefer to spend your leisure time?
__________________________________________________________________

9. Please share any concerns or questions you have about moving to our facility:
__________________________________________________________________

10. How did you hear about Pinky Promise Creators?
__________________________________________________________________


Once completed, please return this application and questionnaire to the Pinky Promise Creators admissions office. Thank you for considering our facility as your home! We look forward to getting to know you better.