Looking for Care | Bridgeway Care Connections

Who are you searching for?

Choose the person you are looking for care for.

✓ Spouse ✓ Myself ✓ Mom ✓ Dad ✓ Someone else

What prompted your search for senior living or care?

Select the reason that best describes your situation.

✓ Help with daily activities ✓ Memory care needs ✓ Placement post-hospital or short-term rehab ✓ Socialization and companionship ✓ Starting to plan for the future ✓ Other

What is your timing?

How quickly do you need to find an option?

✓ Immediately ✓ Within a few months ✓ Within 6 months ✓ Not urgent ✓ Not sure

Where is the person currently living?

This helps us understand the current living situation.

✓ Home alone ✓ Home with spouse, family or friends ✓ Staying with family temporarily ✓ In a senior living community ✓ Currently in the hospital ✓ Short-term rehab ✓ Other

How old is the person needing care?

Choose the age range that best describes them.

55 - 64 65 - 74 75 - 84 85 +

What is the person’s name?

We use this for our records and to personalize follow-up. We will not contact the person unless you ask us to.

First name

Last name

Full name

How is the person getting around?

Choose the closest description.

✓ Walks independently ✓ Uses a cane or walker ✓ Uses a wheelchair ✓ Needs significant mobility assistance ✓ Other / not sure

Does the person need help with the following?

Select all that apply.

✓ Bathing / showering ✓ Dressing ✓ Toileting ✓ Eating / meals ✓ Medication reminders ✓ Housekeeping / laundry ✓ Transportation ✓ None / independent ✓ Not sure

Has the person experienced any behaviors related to memory loss?

Select all that apply, or choose “None / not sure”.

✓ Forgetfulness ✓ Confusion or disorientation ✓ Wandering / exit-seeking ✓ Agitation or anxiety ✓ Difficulty with daily routines ✓ None / no known behaviors ✓ Not sure

What would the person like in a community?

Select all preferences that are important.

Anything else that is important? (optional)

How does the person plan to pay for care?

Choose the option that best describes the expected source of funds.

✓ Private pay ✓ Long-term care insurance ✓ Medicaid / public benefits ✓ Veterans benefits ✓ Combination of sources ✓ Not sure

Is the person or their spouse a wartime Veteran?

This may help identify relevant benefit information.

✓ Yes ✓ No ✓ Not sure

What monthly budget are you considering?

An approximate range is enough.

✓ Below $1,500/month ✓ $1,500–$3,000/month ✓ $3,001–$5,000/month ✓ $5,001–$7,500/month ✓ $7,501+/month ✓ Not sure

Preferred start date (optional)

Tell us who we should contact

We need your details so Bridgeway can follow up about the request.

Your full name *

Email address *

Phone number *

Privacy: Please do not submit medical records, diagnoses, medication lists, Social Security numbers, financial account details, or other highly sensitive information in this form.

Find the right care for your loved one

Care assessment