Let Our Experience Be Your Guide

Simply fill out the short form below, and MyGuide for Seniors will do the research for you... at NO charge. The more information you provide, the better our ability to match your needs. If you would prefer to have assistance with our service, just call 215.361.3219.

Our specialists will then review your responses and reach out to the providers that best meet your needs. We will email you the names and contact information of those providers within 48 hours.

ALL INFORMATION IS CONFIDENTIAL. Personal information will be shared with qualified providers that meet your current needs. NO information of any kind will be sold, or given to outside marketing services.

All fields denoted with an asterisk (*) are required.

Your Information

Prefix - First Name*
MI - Last Name*
Address* / Apt No	/
City* / State* / Zip*	/ /
Primary Email Address*
Secondary Email Address
Primary Phone*	- -
Secondary Phone	- -
How Best to Contact*
Decision Timing*

First Individual (for whom you are searching)

Relation*
First Name
Last Name
Agreeable to search
Current Living Situation
Age of First Individual
Is there a Pet

Second Individual (for whom you are searching)

Relation
First Name
Last Name
Agreeable to search
Current Living Situation
Age of Second Individual

Location of Interest (State and City, or Zip)

Location*
State & City or Zip

Additional Information

Services Needed (Please check one or more)
Independent Living	Assisted Living
Skilled Nursing	CCRC Community (Age in Place)
Current health issues that may assist provider? (Please check any that apply)
Arthritis	Ambulatory Restrictions
Aquatic Therapy	Alzheimer's / Dementia
Diabetes	Heart Disease
Incontinence	Macular Degeneration
Parkinson's	Bathing Assistance
Stroke	Medication Assistance
Funding Source(s) (Please check one or more)
Private Pay	Long Term Care Insurance
Unknown
Amount Budgeted to Pay Monthly (Please check one)
Unknown	$1,500 - $2,000
$2,000 - $2,500	$2,500 - $3,000
$3,000 - $4,000	$5,000 +
Do you have a need for any of the following?
Estate Planning	Seniors Certified Realtor
Wills	Home Organization Services
Hearing Aids	Medical Needs Assessment
Oxygen	Physical Needs Assessment
Motorized Scooters	Personal Medical Alarms
Wheelchairs	Health Insurance Services
Prescription Services	Long Term Care Insurance
Are there any other items that will assist in search process? General Comments

Yes! I want FREE access to the entire MyGuide for Seniors' website! With my login ID I can:

Get our E-book: MyGuide for Seniors - What You Need To Know About Choosing A Senior Living Community
Create a MyCommunities folder of my favorite senior living communities.
Ask a question of MyGuide's advising Gerontologist and Certified Geriatric Care Manager.

SEND SEARCH REQUEST

By clicking on the Send Search Request button I understand that my information will be sent to related providers and services that meet the requirements that I have denoted above. I also understand that MyGuide for Seniors keeps all collected information confidential and only given to parties that can assist me with my requested needs.

Resources

"My mother had a stroke and was in rehab... and was failing. Dad did not know what to do. MyGuide for Seniors found us the right community within days... Mom was moved there, and a month later Dad decided to move in also."

Susan H.

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