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[showif [DoThis]=Login] [append db=db/needs.db][FORMVARIABLES][Middle StartAfter="&EndBefore="][NAME][/Middle]=[VALUE]&[/FORMVARIABLES][/append] [sendmail to=[!]dave@mobilinkpro.com[/!]tenawells1@gmail.com&from=dave@westcoastapps.net&subject=New Senior Housing Needs Assessment Request] Date: [date] Name: [lookup db=db/needs.db&value=[SKU]&lookinfield=SKU&returnfield=NAME] Phone: [lookup db=db/needs.db&value=[SKU]&lookinfield=SKU&returnfield=PHONE] City: [lookup db=db/needs.db&value=[SKU]&lookinfield=SKU&returnfield=CITY] State: [lookup db=db/needs.db&value=[SKU]&lookinfield=SKU&returnfield=STATE] Minimum Budget: [lookup db=db/needs.db&value=[SKU]&lookinfield=SKU&returnfield=MIN-BUDGET] Maximum Budget: [lookup db=db/needs.db&value=[SKU]&lookinfield=SKU&returnfield=MAX-BUDGET] Current Living Situation: [lookup db=db/needs.db&value=[SKU]&lookinfield=SKU&returnfield=LIVING] Referred By: [lookup db=db/needs.db&value=[SKU]&lookinfield=SKU&returnfield=REFERRED] Additional Information: [lookup db=db/needs.db&value=[SKU]&lookinfield=SKU&returnfield=ADDITIONAL-INFO] Dressing: [lookup db=db/needs.db&value=[SKU]&lookinfield=SKU&returnfield=DRESSING] Help Feeding: [lookup db=db/needs.db&value=[SKU]&lookinfield=SKU&returnfield=FEEDING] Bladder Incontenence: [lookup db=db/needs.db&value=[SKU]&lookinfield=SKU&returnfield=INCONTINENCE-BLADDER] Bowel Incontenence: [lookup db=db/needs.db&value=[SKU]&lookinfield=SKU&returnfield=INCONTINENCE-BOWEL] Help Moving: [lookup db=db/needs.db&value=[SKU]&lookinfield=SKU&returnfield=MOVING] Memory Issues: [lookup db=db/needs.db&value=[SKU]&lookinfield=SKU&returnfield=MEMORY] Dementia: [lookup db=db/needs.db&value=[SKU]&lookinfield=SKU&returnfield=DEMENTIA] Help Showering: [lookup db=db/needs.db&value=[SKU]&lookinfield=SKU&returnfield=SHOWERING] Can You Walk: [lookup db=db/needs.db&value=[SKU]&lookinfield=SKU&returnfield=WALKING] Diabetes: [lookup db=db/needs.db&value=[SKU]&lookinfield=SKU&returnfield=DIABETES] Macular: [lookup db=db/needs.db&value=[SKU]&lookinfield=SKU&returnfield=MACULAR] Parkinsons: [lookup db=db/needs.db&value=[SKU]&lookinfield=SKU&returnfield=PARKINSONS] Mental Disabilities: [lookup db=db/needs.db&value=[SKU]&lookinfield=SKU&returnfield=MENTAL] [/sendmail] [/showif] [Hideif [DoThis]=Login]

SENIOR HOUSING NEEDS ASSESSMENT

Please complete the Housing Needs Form to the best of your ability, so we can determine the most appropriate care solutions and support for you and your situation.

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[!]*******Create Random Sku**********[/!] [text]SkuLength=8[/text] [text]Chars=abcdefghijkmpqrstuvwxyz23456789[/text] [text]Max=[countchars][Chars][/countchars][/text] [text]SKU=[/text] [loop start=1&end=[SkuLength]] [text]X=[math]ceil([random format=float]*[Max])[/math][/text] [text]SKU=[SKU][getchars start=[X]&end=[X]][Chars][/getchars][/text] [/loop] [showif [DoThis]=Login]

Thank you. Your information has been submitted successfully. A Senior Housing Professional is analyzing your details and will be in contact with you shortly to discuss your housing options.

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Needs Assistance With: (Check all that apply)

Personal details:

Current living situation:

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