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| What PARKER current continuum care services are you interested in?: |
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| If you are interested in Skilled Nursing or Memory Care, what do you want your Status to be?: |
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| If you selected active status, what is your estimated time of need?: |
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| Which of our nursing care residences would you be interested in for admission? Please check all that apply: |
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| How active do you consider yourself? (please select one): |
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| Where do you currently live? (please select one): |
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| In the next five – ten years, where do you expect to be living? (please select one): |
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| Do you currently need support at home from a Home Health Aide/Companion or Caregiver?: |
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| If so, how often do you receive assistance from a paid Home Health Aide/Companion or Caregiver?: |
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| Are you currently a caregiver to a family member or friend?: |
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| If so, how many hours a day are you a caregiver? (please select one): |
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| What Parker future continuum care services would you be interested in? (check all that apply): |
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| Which of the following categories best describes your total annual household income from all sources before taxes including wages, pensions, investments and social security? (please select one): |
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