Placement Navigation Intake

Tell Us What Your Family Needs

Share your priorities so Capricorn can identify participating providers worth considering.

FAMILY DECISION RESPONSIBILITY

Capricorn does not make the final provider decision. Families remain responsible for reviewing profiles, asking questions, touring locations, evaluating provider agreements and selecting the provider they consider appropriate.

Family Contact

About Your Loved One

Timeline & Mobility

Care Needs

Location & Preferences

Budget & Priorities

Decision-Making & Review

Step 1 of 7

1Family / Primary Contact

Family Contact Name *

Relationship to Senior *

Phone Number *

Email Address *

Best Time to Contact

Preferred Contact Method

2About Your Loved One

Senior's Name *

Age *

Current City *

State *

Current Living Situation *

What type of placement are you considering? *

Select all that apply.

Assisted LivingMemory CareResidential Care / Group HomeSmaller Boutique Residential HomeHospice-Friendly Residential SettingNot Sure — We Need Guidance

2Reason for Seeking Care

Please check all that apply.

Recent HospitalizationRehabilitation DischargeFalls or Mobility ConcernsIncreasing Help With Daily ActivitiesMemory ChangesConfusionSafety ConcernsWandering ConcernsCaregiver ExhaustionSenior Living AloneIncreasing Supervision NeededCurrent Home Is No Longer AppropriateWant Senior Closer to FamilyOther

Please briefly tell us what is happening

3Placement Timeline

How soon is placement needed? *

Preferred Move-In Date

3Mobility

The senior currently:

Walks IndependentlyUses a CaneUses a WalkerUses a WheelchairNeeds Help TransferringRequires Two-Person AssistanceHas Very Limited Mobility / Primarily BedboundOther

Recent Falls?

4Daily Personal Care

Does the senior need help with any of the following?

BathingDressingGroomingToiletingEatingWalking / MobilityTransfersContinence CareMeal PreparationNone of the Above

How much supervision is generally needed?

4Memory & Cognitive Support

No Known Memory ConcernsMild ForgetfulnessMild Cognitive ImpairmentDementia DiagnosisAlzheimer's DiseaseConfusion / DisorientationWandering RiskNeeds a Secured EnvironmentSundowningNighttime ConcernsBehavioral ConcernsNot Sure

Please describe any memory, behavioral, safety, or supervision concerns

4Health & Care Considerations

DiabetesInsulin-Related Support ConsiderationsOxygenWound-Care CoordinationHospiceHome HealthSpecial DietSwallowing ConcernsMedication Supervision / SupportIncontinence SupportCatheter / OstomyDialysisSeizure HistoryChronic PainFall-Risk ConcernsOther

Medication Support

Additional health or medication information we should know

4Equipment Currently Used

WalkerWheelchairHospital BedOxygen EquipmentTransfer / Lift DeviceShower ChairNoneOther

5Preferred Location

Please check all areas you would consider

AllenMcKinneyFairviewPlanoFriscoDallasRowlettOther

Preferred Distance From Family

Preferred City, ZIP Code, Neighborhood, or Area

5Room & Home Preferences

Room Preference

Environment Preferences

Smaller Home-Like SettingLarger Assisted-Living CommunityQuiet EnvironmentActivities & SocializationOutdoor SpaceMemory-Care ExperienceHospice-FriendlyClose to FamilyFaith PreferenceCultural / Language PreferenceOther

Faith, Cultural, or Language Preference, if any

6Monthly Budget

Approximate Monthly Budget

Expected Payment Source

Additional Budget or Financial Considerations

6What Matters Most to Your Family?

Please select up to five priorities

Quality of CareSafetyLocationAffordabilityPrivate RoomSmaller Residential HomeMemory-Care CapabilityExperienced CaregiversCleanlinessActivities / SocializationFamily CommunicationAccessibilityAbility to Accommodate Changing NeedsHospice-Friendly EnvironmentCultural / Faith FitOther

What are the THREE most important things you are looking for in your loved one's new home?

7Family Decision-Making

Who will participate in the placement decision?

Prospective ResidentSpouseAdult Child / ChildrenMultiple Family MembersLegal RepresentativeOther

Primary Decision Maker / Contact

Is the family generally in agreement about exploring placement?

Would you like help coordinating provider conversations or tours?

7Anything Else We Should Know?

7Family Authorization

I authorize Capricorn Group Care to contact me regarding senior-care placement and transition support and to use the information I voluntarily provide to assist with placement navigation.I understand that, when appropriate and authorized, Capricorn may discuss relevant placement information with participating providers for the purpose of exploring potential placement options.I understand that Capricorn Group Care provides placement navigation and coordination and does not guarantee provider availability, acceptance, admission, pricing, or length of stay.I understand that receiving providers conduct their own assessments and independently determine their capabilities, eligibility requirements, pricing, availability, and admission decisions.

Type your full name as your signature *

Please do not submit highly sensitive medical records, diagnosis details, medication lists, insurance documents, or other protected health information through this general form unless specifically requested through our secure intake portal. A Capricorn care coordinator will contact you to securely complete additional healthcare documentation if needed.