Seniors Resource Guide Free Book Offer

www.SeniorsResourceGuide.com

Want a FREE resource book?
Tell us what you are looking for and we will send you a book of your choice at no charge.

Thank you for your interest in our books. We will send you a FREE book and put you in contact with a company representative in any of the following topics you select. In appreciation of you considering our affiliates' services, your first book will be at no charge. To receive a free book, all you have to do is fill out this form and click "Order Your Book Now!" below.

— The staff at SeniorsResourceGuide.com and our affiliates.

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Contact Information:

*Your Name:

*Your E-mail Address:

*Your Day Phone Number:

*Address:

*City, State

*Your Zip Code:

*I am inquiring for:
Self Friend Relative – Relationship

If other than you, what is the person's first name and age that this Needs Survey is for:
First Name Age

Please provide the desired location for the senior housing, service(s) or product(s) to be provided:

*Areas we cover:

Select as many topics in which you are interested from the following list,
but you must select at least one to get your free book.

Senior Housing:
In order to serve you better please give us a specific city or area such as "North Denver" or "Fort Myers, FL", etc.

Are you interested in senior housing or other services in a specific county, state.

What do you want information on:

Senior Housing

Continuum of Care

Assisted Living

Retirement Communities

Skilled Nursing

Active Independent Living

Alzheimer's Assisted Living

Subsidized Housing

Alzheimer's Skilled Nursing

How much have you budgeted for these types of housing services?
To better assist you we need to know your approximate housing budget.

Less than $1,000 a month

$1,000 to $3,000

$3,000 to $5,000

$5,000 and over

Are you looking for income qualifying housing such as HUD
Yes No

Health at Home

Home Health/Caregiver

Ambulatory Aids such as wheelchairs and walkers

Homemakers & Companions

Diabetic Supplies

Emergency Response Systems

Home Medical Equipment

Health Services

Adult Day Programs

Rehabilitation

Hospitals

Dental Resources

Hospices

Hearing Resources

HMOs and Health Insurance

Vision Resources

Prescription Assistance

Respite Care

Professional and Advisory Services

Care Management

Long-Term Care Insurance

Elder Law

Moving Services

Estate Planning

Funeral & Preplanning Services

Financial Planning

Real Estate Services

Reverse Mortgages

Other – please describe your needs

Other (please explain):

Do you have any suggestions for our website?

Select Your FREE Book
Note: We allow one free book per mailing address.
For additional books at $2.00 each, click here.

Collier-Lee Counties, Florida (Large Format Book)
Colorado Springs, Colorado
Bergen-Passaic Counties, New Jersey
Denver, Colorado – North Denver
Denver, Colorado – South Denver
Essex-Hudson-Union Counties, New Jersey
Grand Junction & Western Slope, Colorado
Mississippi Gulf Coast & Hattiesburg, Mississippi
Mobile, Alabama
Morris-Somerset Counties, New Jersey
Northern Colorado
Pueblo-Cañon City, Colorado
Salt Lake City, Utah

Other Information

When do you expect to need senior housing, service(s) or product(s):
Now In the Next 6 Months 6 to 12 months

If you are in need of senior housing or home health care, what type of funding will you use:

Private Pay		Medicare
Long Term Care Insurance		Medicaid or Public Assistance
Health Insurance		Veteran Benefits

The Seniors Resource Guide considers the information on this form confidential. Please read our Privacy Statement before submitting this form:

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