Questionnaire Home / Questionnaire  1 Step 1 First Name DOBdate_range Family Name Spouses First Name DOBdate_range Spouses Family Nameyour full name Address Street Number Street Name City Postal Code Phone number Cell Number Email addressemail Please check oneSingleMarried Widow Widower Do you have any preferences where your retirement home should be located? List city When would you like to start looking for a residence? Approx. Month and Year Would you like to be in a residence where someone speaks your mother tongue or other language other than English Do you have any dietary concerns? If so, please state 0 / Are you on medication? If so, please let us knowYesNo Do you have mobility problems? 0 / Ie. Walker Cane scooter What type of accommodations would you be looking for?Single One Bedroom Two BedroomBungalow Do you have any special requests? Please let us know 0 / I Agree To The Following Terms And Conditions We Keep Your Personal Data Totally Protected. You Also Agree To Notify Seniors in Progress About Any Signing or Potential View of Any Retirement Home Without Notifying Seniors in Progress First. Submit keyboard_arrow_leftPrevious Nextkeyboard_arrow_right FormCraft - WordPress form builder REMEMBER This service is absolutely FREE. There are no hidden or extra charges. We are here to help you.