Family Care Questionnaire

This page is for families in the Inland Empire seeking senior placement and care navigation guidance, including assisted living, memory care, and RCFE support.

Prefer to talk first? Call +1 (909) 707-4003 for phone support.

Family Intake Questionnaire

Family Care Questionnaire

Complete this questionnaire so our team can better understand your family’s needs and provide compassionate, local senior living guidance.

Privacy notice: Information shared here is used only by Lightbearer Senior Care Solutions to follow up and help guide your family.

Loved One First Name

Loved One Last Name

Loved One Age

Preferred Placement City or Area *

How Soon Is Placement Needed *

Current Living Situation

Care Setting Interest (select all that apply)

Assisted Living Memory Care RCFE / Residential Care Home Not sure yet

Estimated Monthly Budget Range

Mobility Support Level

Primary Diagnosis or Care Concern

Primary Insurance (if known)

Primary Contact Name *

Relationship to Loved One

Best Phone Number *

Email Address

Preferred Contact Method

Best Time to Reach You

Additional Support Needs (select all that apply)

Fall risk support Medication management Dementia behavior support Hospice or palliative coordination

Additional Notes

Family fee disclosure: Lightbearer Senior Care Solutions does not charge families a fee for placement guidance. Community availability, pricing, services, licensing, and admission decisions are determined independently by each provider.

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