Are you sure you want to exit? Your progress will be lost.
Who are you caring for?
Which best describes their mobility?
How well are they maintaining their hygiene?
How are they managing their medications?
Does their living environment pose any safety concerns?
Fall risks, spoiled food, or other threats to wellbeing
Are they experiencing any memory loss?
Which best describes your loved one's social life?
Acknowledgment of Disclosures and Authorization
By proceeding, I agree that I understand the following disclosures:
I. How We Work in Washington. Based on your preferences, we provide you with information about one or more of our contracted senior living providers ("Participating Communities") and provide your Senior Living Care Information to Participating Communities. The Participating Communities may contact you directly regarding their services. APFM does not endorse or recommend any provider. It is your sole responsibility to select the appropriate care for yourself or your loved one. We work with both you and the Participating Communities in your search. We do not permit our Advisors to have an ownership interest in Participating Communities.
II. How We Are Paid. We do not charge you any fee – we are paid by the Participating Communities. Some Participating Communities pay us a percentage of the first month's standard rate for the rent and care services you select. We invoice these fees after the senior moves in.
III. When We Tour. APFM tours certain Participating Communities in Washington (typically more in metropolitan areas than in rural areas.) During the 12 month period prior to December 31, 2017, we toured 86.2% of Participating Communities with capacity for 20 or more residents.
IV. No Obligation or Commitment. You have no obligation to use or to continue to use our services. Because you pay no fee to us, you will never need to ask for a refund.
V. Complaints. Please contact our Family Feedback Line at (866) 584-7340 or ConsumerFeedback@aplaceformom.com to report any complaint. Consumers have many avenues to address a dispute with any referral service company, including the right to file a complaint with the Attorney General's office at: Consumer Protection Division, 800 5th Avenue, Ste. 2000, Seattle, 98104 or 800-551-4636.
VI. No Waiver of Your Rights. APFM does not (and may not) require or even ask consumers seeking senior housing or care services in Washington State to sign waivers of liability for losses of personal property or injury or to sign waivers of any rights established under law.I agree that: A.I authorize A Place For Mom ("APFM") to collect certain personal and contact detail information, as well as relevant health care information about me or from me about the senior family member or relative I am assisting ("Senior Living Care Information"). B.APFM may provide information to me electronically. My electronic signature on agreements and documents has the same effect as if I signed them in ink. C.APFM may send all communications to me electronically via e-mail or by access to an APFM web site. D.If I want a paper copy, I can print a copy of the Disclosures or download the Disclosures for my records. E.This E-Sign Acknowledgement and Authorization applies to these Disclosures and all future Disclosures related to APFM's services, unless I revoke my authorization. You may revoke this authorization in writing at any time (except where we have already disclosed information before receiving your revocation.) This authorization will expire after one year. F.You consent to APFM's reaching out to you using a phone system than can auto-dial numbers (we miss rotary phones, too!), but this consent is not required to use our service.
✔
I acknowledge and authorize
✔
I consent to the collection of my consumer health data.*
✔
I consent to the sharing of my consumer health data with qualified home care agencies.*
*If I am consenting on behalf of someone else, I have the proper authorization to do so. By clicking Get My Results, you agree to our Privacy Policy. You also consent to receive calls and texts, which may be autodialed, from us and our customer communities. Your consent is not a condition to using our service. Please visit our Terms of Use. for information about our privacy practices.
Mostly Independent
Your loved one may not require home care or assisted living services at this time. However, continue to monitor their condition for changes and consider occasional in-home care services for help as needed.
Remember, this assessment is not a substitute for professional advice.
Share a few details and we will match you to trusted home care in your area:
Check with your State's Secretary of State, or Department of Aging Services, or someplace on your state's government website. My state has standard forms for POA and Health Care Directive. You can also read your state's laws regarding Inheritance. My state has a chart showing how the Probate court will divide your property, if you don't have a Will, and they have a FAQ section with things like "Can I dis-inherit a child?" (Yes) and "Can I write my spouse out of my Will?" (No, not in our state). If you're needing free advice, best place to look is on the website of state which your property is in, and where you reside.
Always get legal advice when it comes to any type of legal document, such as a Will. Just one misplaced word in a made at home Will could create terrible results.
There are tons of different ones online that are free. I would go to Google and type in something like Free Last Will and Testament and add words like "printable" or "template" if you want to type in it. Also, add the state you are in. When we did ours, my husband and I made a few originals. We had the witnesses and notary sign and stamp each one. The following is just a short form from All Law. LAST WILL OF _________________
I, ____________________________, a resident of the state of ______________________, being of sound and disposing mind and memory, at least 18 years of age, and not actuated by any duress, menace, fraud, mistake, or undue influence, do freely make, publish, and declare this to be my last Will, hereby expressly revoking all Wills and Codicils previously made by me.
I. EXECUTOR
I appoint _________________ as Executor of this my Last Will and Testament and provide if this Executor is unable or unwilling to serve then I appoint _________________ as alternate Executor. My Executor shall be authorized to carry out all provisions of this Will and pay my just debts, obligations and funeral expenses. I further provide my Executor shall not be required to post surety bond in this or any other jurisdiction, and direct that no expert appraisal be made of my estate unless required by law.
II. GUARDIAN
In the event I shall die as the sole parent of minor children, then I appoint _________________ Guardian of said minor children. If this named Guardian is unable or unwilling to serve, then I appoint _________________ alternate.
III. MARITAL STATUS
I declare that I am married to ________________________ and that all references in this Will to my spouse are references to him/her.
IV. SIMULTANEOUS DEATH OF SPOUSE
In the event that my spouse shall die simultaneously with me or there is no direct evidence to establish that my spouse and I died other than simultaneously, I direct that I shall be deemed to have predeceased my spouse, notwithstanding any provision of law to the contrary, and that the provisions of my Will shall be construed on such presumption.
V. SIMULTANEOUS DEATH OF BENEFICIARY
If any beneficiary of this Will, including any beneficiary of any trust established by this Will, other than my spouse, shall die _________________ within 60 days of my death or prior to the distribution of my estate, I hereby declare that I shall be deemed to have survived such person.
VI. BEQUESTS
IN WITNESS WHEREOF, I, ____________________________________, hereby set my hand to this last Will, on each page of which I have placed my initials, on this _____ day of ____________, 20__.
______________________
Signature
The foregoing instrument, consisting of _____ pages, including this page, was signed in our presence by __________________________ and declared by him/her to be his/her last Will.
______________________
Witness
______________________
Address
______________________
______________________
______________________
Date
______________________
Witness
______________________
Address
______________________
______________________
______________________
Date
______________________
Witness
______________________
Address
______________________
______________________
______________________
Date
COUNTY OF )
STATE OF )
Subscribed and sworn before me this _____ day of ____________, 20__.
Witness my hand and seal.
________________________________________________ My commission expires:
By proceeding, I agree that I understand the following disclosures:
I. How We Work in Washington.
Based on your preferences, we provide you with information about one or more of our contracted senior living providers ("Participating Communities") and provide your Senior Living Care Information to Participating Communities. The Participating Communities may contact you directly regarding their services.
APFM does not endorse or recommend any provider. It is your sole responsibility to select the appropriate care for yourself or your loved one. We work with both you and the Participating Communities in your search. We do not permit our Advisors to have an ownership interest in Participating Communities.
II. How We Are Paid.
We do not charge you any fee – we are paid by the Participating Communities. Some Participating Communities pay us a percentage of the first month's standard rate for the rent and care services you select. We invoice these fees after the senior moves in.
III. When We Tour.
APFM tours certain Participating Communities in Washington (typically more in metropolitan areas than in rural areas.) During the 12 month period prior to December 31, 2017, we toured 86.2% of Participating Communities with capacity for 20 or more residents.
IV. No Obligation or Commitment.
You have no obligation to use or to continue to use our services. Because you pay no fee to us, you will never need to ask for a refund.
V. Complaints.
Please contact our Family Feedback Line at (866) 584-7340 or ConsumerFeedback@aplaceformom.com to report any complaint. Consumers have many avenues to address a dispute with any referral service company, including the right to file a complaint with the Attorney General's office at: Consumer Protection Division, 800 5th Avenue, Ste. 2000, Seattle, 98104 or 800-551-4636.
VI. No Waiver of Your Rights.
APFM does not (and may not) require or even ask consumers seeking senior housing or care services in Washington State to sign waivers of liability for losses of personal property or injury or to sign waivers of any rights established under law.
I agree that:
A.
I authorize A Place For Mom ("APFM") to collect certain personal and contact detail information, as well as relevant health care information about me or from me about the senior family member or relative I am assisting ("Senior Living Care Information").
B.
APFM may provide information to me electronically. My electronic signature on agreements and documents has the same effect as if I signed them in ink.
C.
APFM may send all communications to me electronically via e-mail or by access to an APFM web site.
D.
If I want a paper copy, I can print a copy of the Disclosures or download the Disclosures for my records.
E.
This E-Sign Acknowledgement and Authorization applies to these Disclosures and all future Disclosures related to APFM's services, unless I revoke my authorization. You may revoke this authorization in writing at any time (except where we have already disclosed information before receiving your revocation.) This authorization will expire after one year.
F.
You consent to APFM's reaching out to you using a phone system than can auto-dial numbers (we miss rotary phones, too!), but this consent is not required to use our service.
LAST WILL OF _________________
I, ____________________________, a resident of the state of ______________________, being of sound and disposing mind and memory, at least 18 years of age, and not actuated by any duress, menace, fraud, mistake, or undue influence, do freely make, publish, and declare this to be my last Will, hereby expressly revoking all Wills and Codicils previously made by me.
I. EXECUTOR
I appoint _________________ as Executor of this my Last Will and Testament and provide if this Executor is unable or unwilling to serve then I appoint _________________ as alternate Executor. My Executor shall be authorized to carry out all provisions of this Will and pay my just debts, obligations and funeral expenses. I further provide my Executor shall not be required to post surety bond in this or any other jurisdiction, and direct that no expert appraisal be made of my estate unless required by law.
II. GUARDIAN
In the event I shall die as the sole parent of minor children, then I appoint _________________ Guardian of said minor children. If this named Guardian is unable or unwilling to serve, then I appoint _________________ alternate.
III. MARITAL STATUS
I declare that I am married to ________________________ and that all references in this Will to my spouse are references to him/her.
IV. SIMULTANEOUS DEATH OF SPOUSE
In the event that my spouse shall die simultaneously with me or there is no direct evidence to establish that my spouse and I died other than simultaneously, I direct that I shall be deemed to have predeceased my spouse, notwithstanding any provision of law to the contrary, and that the provisions of my Will shall be construed on such presumption.
V. SIMULTANEOUS DEATH OF BENEFICIARY
If any beneficiary of this Will, including any beneficiary of any trust established by this Will, other than my spouse, shall die _________________ within 60 days of my death or prior to the distribution of my estate, I hereby declare that I shall be deemed to have survived such person.
VI. BEQUESTS
IN WITNESS WHEREOF, I, ____________________________________, hereby set my hand to this last Will, on each page of which I have placed my initials, on this _____ day of ____________, 20__.
______________________
Signature
The foregoing instrument, consisting of _____ pages, including this page, was signed in our presence by __________________________ and declared by him/her to be his/her last Will.
______________________
Witness
______________________
Address
______________________
______________________
______________________
Date
______________________
Witness
______________________
Address
______________________
______________________
______________________
Date
______________________
Witness
______________________
Address
______________________
______________________
______________________
Date
COUNTY OF )
STATE OF )
Subscribed and sworn before me this _____ day of ____________, 20__.
Witness my hand and seal.
________________________________________________ My commission expires:
Notary public