Pay Your Way | Mom's Florida Place

Select At Least One Option Below;

Are you engaging here as the person needing support in transitioning into a Senior Living Community (SLC)?

Are you engaging here as the spouse of a couple, and both of you are needing support in transitioning into a SLC?

Are you the spouse of the person transitioning into a SLC?

Are you the legal Power of Attorney for the senior transitioning into a SLC?

Other

First name

Last name

Email

Phone

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

If you filled out the above and you are NOT the senior, please add the senior('s) complete contact details including address and phone number.

Do you already know what neighborhood, town, city or region you wish to live in? Please list them out here.

Are you active in a religious community or social club that you plan to remain active with after moving to the SLC? If so, please provide the location information below.

What city or region do you have close friends or family living, which you seek to also live near? Please list their names and address below.

Is the senior, or the senior’s spouse, a USA Veteran with a DD-214 form?

YES

NO

Other

What event in your life recently occurred, that led you to consider moving into a senior living community (SLC)?

Do you expect visitors at your SLC that are from out of the region?

No

Yes

Would they want over night accommodations at your SLC, or near by at a Hotel?

Lodging at SLC

Lodging at Hotel

Other

The senior living industry regularly uses a measure named Activities of Daily Living (ADL).

ADL Hierarchy of Loss

Research shows ADLs are typically lost in this order: bathing → dressing → toileting → transferring → continence → feeding. This pattern helps predict future care needs. If a community member is losing bathing independence, dressing difficulty may follow.]

Self Assessment Starts Now.

Bathing ADL #1. The ability to wash oneself, including getting in and out of a bathtub or shower. Sponge bathing. Tub bathing. Showering. Washing hair. Grooming tasks.

I Require Assistance.

I Rarely Require Assistance.

No Assistance Needed.

Dressing ADL #2. Selecting appropriate clothing and putting it on, including fastening buttons and zippers. Choosing weather-appropriate clothes. Putting on undergarments. Fastening buttons/zippers. Putting on shoes and socks.

I Require Assistance.

I Rarely Require Assistance.

No Assistance Needed.

Toileting ADL #3. Getting to and from the toilet, using it, and managing clothing before and after. Getting on/off the toilet. Cleansing oneself. Managing clothing. Using bedpan or commode if needed.

I Require Assistance.

I Rarely Require Assistance.

No Assistance Needed.

Transferring ADL #4. Moving in and out of a bed or chair without assistance. Getting in/out of bed. Getting in/out of chair. Standing from seated position. Wheelchair transfers.

I Require Assistance.

I Rarely Require Assistance.

No Assistance Needed.

Continence ADL #5. Maintaining control of bladder and bowel function. Bladder control. Bowel control. Managing incontinence products. Recognizing need to use toilet.

I Require Assistance.

I Rarely Require Assistance.

No Assistance Needed.

Feeding ADL #6. The ability to feed oneself, including cutting food and bringing it to the mouth. Using utensils. Cutting food. Bringing food to mouth. Chewing and swallowing. Drinking from a cup.

I Require Assistance.

I Rarely Require Assistance.

No Assistance Needed.

Our service, Mom’s Florida Place, is complimentary. We are paid by the Senior Living Community (SLC) in the form of a referral. The business model of our service fails if you, the client, has already entered your details into one of the LIST BROKERING Nationwide websites serving curios senior seeking to transition to SLC. In these cases, if you seek to work with Mom’s Florida Place, you will need to sign an atestment letter stating that you are no longer working with any other senior placement service, and that Mom’s Florida Place is your rightful representative in this process of moving to a SLC. A form letter capturing these statements will be presented to you at our initial consultation, for you to review and sign.

By hitting 'submit', you are giving permission to Mom's Florida Place to contact you at your provided contact details. All automated communications will include an opt-out option should you seek to do so. Thank you.

Onboarding and Scheduling Initial Consultation