Are you sure you want to exit? Your progress will be lost.
Who are you caring for?
Which best describes their mobility?
How well are they maintaining their hygiene?
How are they managing their medications?
Does their living environment pose any safety concerns?
Fall risks, spoiled food, or other threats to wellbeing
Are they experiencing any memory loss?
Which best describes your loved one's social life?
Acknowledgment of Disclosures and Authorization
By proceeding, I agree that I understand the following disclosures:
I. How We Work in Washington. Based on your preferences, we provide you with information about one or more of our contracted senior living providers ("Participating Communities") and provide your Senior Living Care Information to Participating Communities. The Participating Communities may contact you directly regarding their services. APFM does not endorse or recommend any provider. It is your sole responsibility to select the appropriate care for yourself or your loved one. We work with both you and the Participating Communities in your search. We do not permit our Advisors to have an ownership interest in Participating Communities.
II. How We Are Paid. We do not charge you any fee – we are paid by the Participating Communities. Some Participating Communities pay us a percentage of the first month's standard rate for the rent and care services you select. We invoice these fees after the senior moves in.
III. When We Tour. APFM tours certain Participating Communities in Washington (typically more in metropolitan areas than in rural areas.) During the 12 month period prior to December 31, 2017, we toured 86.2% of Participating Communities with capacity for 20 or more residents.
IV. No Obligation or Commitment. You have no obligation to use or to continue to use our services. Because you pay no fee to us, you will never need to ask for a refund.
V. Complaints. Please contact our Family Feedback Line at (866) 584-7340 or ConsumerFeedback@aplaceformom.com to report any complaint. Consumers have many avenues to address a dispute with any referral service company, including the right to file a complaint with the Attorney General's office at: Consumer Protection Division, 800 5th Avenue, Ste. 2000, Seattle, 98104 or 800-551-4636.
VI. No Waiver of Your Rights. APFM does not (and may not) require or even ask consumers seeking senior housing or care services in Washington State to sign waivers of liability for losses of personal property or injury or to sign waivers of any rights established under law.I agree that: A.I authorize A Place For Mom ("APFM") to collect certain personal and contact detail information, as well as relevant health care information about me or from me about the senior family member or relative I am assisting ("Senior Living Care Information"). B.APFM may provide information to me electronically. My electronic signature on agreements and documents has the same effect as if I signed them in ink. C.APFM may send all communications to me electronically via e-mail or by access to an APFM web site. D.If I want a paper copy, I can print a copy of the Disclosures or download the Disclosures for my records. E.This E-Sign Acknowledgement and Authorization applies to these Disclosures and all future Disclosures related to APFM's services, unless I revoke my authorization. You may revoke this authorization in writing at any time (except where we have already disclosed information before receiving your revocation.) This authorization will expire after one year. F.You consent to APFM's reaching out to you using a phone system than can auto-dial numbers (we miss rotary phones, too!), but this consent is not required to use our service.
✔
I acknowledge and authorize
✔
I consent to the collection of my consumer health data.*
✔
I consent to the sharing of my consumer health data with qualified home care agencies.*
*If I am consenting on behalf of someone else, I have the proper authorization to do so. By clicking Get My Results, you agree to our Privacy Policy. You also consent to receive calls and texts, which may be autodialed, from us and our customer communities. Your consent is not a condition to using our service. Please visit our Terms of Use. for information about our privacy practices.
Mostly Independent
Your loved one may not require home care or assisted living services at this time. However, continue to monitor their condition for changes and consider occasional in-home care services for help as needed.
Remember, this assessment is not a substitute for professional advice.
Share a few details and we will match you to trusted home care in your area:
"Advanced Directives" is, I believe, the name of the kind of document you are seeking. Every state has their own version that can usually be downloaded online. Then there is a remarkable document called "The Five Wishes" that is said to be recognized in every state. It permits one to “ad lib” about how they want to be treated. Several items that I have written into the draft version of my document include items that you might like to consider for your own document:
1. My top care preferences, in order of preferred method are: home care, assisted living, hospital, nursing home. 2. I may well care to return to my home, even if I am dying. 3. I list that there are no limitations on my Patient Advocate’s (Health Care Agent’s) powers. 4. I added additional requests; a. If available/schedulable, I would prefer a single-patient room if confined to or treated in a hospital (except on an emergency basis only). b. Make available personal health information in my personal files if required to establish the need for coordination of current treatment with previous treatment. 5. Under “General Instructions” I have specified that I do not want to be in pain, but just “on the edge” (meaning I do not want to be “out of it”). I want medication only when “needed” (i.e. not continuous without reevaluation). 6. Under “Meaning of ‘Life-Support Treatment’” I have excluded the desire for treatment that offers no hope of benefit. 7. Under “conditions where I do not wish to be kept alive” I have written that: a. Cost is not a factor. b. If my bones are becoming dangerously brittle from osteoporosis or any other systemic bone degradation, please remember that I will be fragile. All care should be taken if am to be transported. Always provide me with support at the back of the neck and provide some elevation of my head. 8. Under “how comfortable I want to be” I have added the type of music that I would like to hear and the type of books that I might like to have read aloud to me when I am near death. 9. With regard to donation of body parts when I die I have written: My organs, at death, that have value, may be harvested before I am cremated, such as liver, eyes, bone marrow, kidneys (if no renal failure). There are other important points to remember, but these thoughts may help you make your own choices.
By proceeding, I agree that I understand the following disclosures:
I. How We Work in Washington.
Based on your preferences, we provide you with information about one or more of our contracted senior living providers ("Participating Communities") and provide your Senior Living Care Information to Participating Communities. The Participating Communities may contact you directly regarding their services.
APFM does not endorse or recommend any provider. It is your sole responsibility to select the appropriate care for yourself or your loved one. We work with both you and the Participating Communities in your search. We do not permit our Advisors to have an ownership interest in Participating Communities.
II. How We Are Paid.
We do not charge you any fee – we are paid by the Participating Communities. Some Participating Communities pay us a percentage of the first month's standard rate for the rent and care services you select. We invoice these fees after the senior moves in.
III. When We Tour.
APFM tours certain Participating Communities in Washington (typically more in metropolitan areas than in rural areas.) During the 12 month period prior to December 31, 2017, we toured 86.2% of Participating Communities with capacity for 20 or more residents.
IV. No Obligation or Commitment.
You have no obligation to use or to continue to use our services. Because you pay no fee to us, you will never need to ask for a refund.
V. Complaints.
Please contact our Family Feedback Line at (866) 584-7340 or ConsumerFeedback@aplaceformom.com to report any complaint. Consumers have many avenues to address a dispute with any referral service company, including the right to file a complaint with the Attorney General's office at: Consumer Protection Division, 800 5th Avenue, Ste. 2000, Seattle, 98104 or 800-551-4636.
VI. No Waiver of Your Rights.
APFM does not (and may not) require or even ask consumers seeking senior housing or care services in Washington State to sign waivers of liability for losses of personal property or injury or to sign waivers of any rights established under law.
I agree that:
A.
I authorize A Place For Mom ("APFM") to collect certain personal and contact detail information, as well as relevant health care information about me or from me about the senior family member or relative I am assisting ("Senior Living Care Information").
B.
APFM may provide information to me electronically. My electronic signature on agreements and documents has the same effect as if I signed them in ink.
C.
APFM may send all communications to me electronically via e-mail or by access to an APFM web site.
D.
If I want a paper copy, I can print a copy of the Disclosures or download the Disclosures for my records.
E.
This E-Sign Acknowledgement and Authorization applies to these Disclosures and all future Disclosures related to APFM's services, unless I revoke my authorization. You may revoke this authorization in writing at any time (except where we have already disclosed information before receiving your revocation.) This authorization will expire after one year.
F.
You consent to APFM's reaching out to you using a phone system than can auto-dial numbers (we miss rotary phones, too!), but this consent is not required to use our service.
Then there is a remarkable document called "The Five Wishes" that is said to be recognized in every state. It permits one to “ad lib” about how they want to be treated. Several items that I have written into the draft version of my document include items that you might like to consider for your own document:
1. My top care preferences, in order of preferred method are: home care, assisted living, hospital, nursing home.
2. I may well care to return to my home, even if I am dying.
3. I list that there are no limitations on my Patient Advocate’s (Health Care Agent’s) powers.
4. I added additional requests;
a. If available/schedulable, I would prefer a single-patient room if confined to or treated in a hospital (except on an emergency basis only).
b. Make available personal health information in my personal files if required to establish the need for coordination of current treatment with previous treatment.
5. Under “General Instructions” I have specified that I do not want to be in pain, but just “on the edge” (meaning I do not want to be “out of it”). I want medication only when “needed” (i.e. not continuous without reevaluation).
6. Under “Meaning of ‘Life-Support Treatment’” I have excluded the desire for treatment that offers no hope of benefit.
7. Under “conditions where I do not wish to be kept alive” I have written that:
a. Cost is not a factor.
b. If my bones are becoming dangerously brittle from osteoporosis or any other systemic bone degradation, please remember that I will be fragile. All care should be taken if am to be transported. Always provide me with support at the back of the neck and provide some elevation of my head.
8. Under “how comfortable I want to be” I have added the type of music that I would like to hear and the type of books that I might like to have read aloud to me when I am near death.
9. With regard to donation of body parts when I die I have written: My organs, at death, that have value, may be harvested before I am cremated, such as liver, eyes, bone marrow, kidneys (if no renal failure).
There are other important points to remember, but these thoughts may help you make your own choices.