Quoter | St. Paul's Senior Care Online Needs Assessment Tool

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1021 West E Street, Belleville, IL 62220 618-233-2095

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Are you inquiring for yourself or a loved one? * Required
- Myself
- A Loved One

What is your relationship? * Required
- Spouse
- Child
- Grandchild
- Niece
- Nephew
- Other

What type of senior community/care are you looking for?
- Independent Living
- Assisted Living
- Memory Care
- Rehabilitation & Extended Stay
What type of senior community/care are you looking for your loved one?
- Independent Living
- Assisted Living
- Memory Care
- Rehabilitation & Extended Stay

Which of our floor plans would most suit your needs?
- One Bedroom
- One Bedroom + Den
- Two Bedroom
- Two Bedroom + Den
- No Preference
Which of our floor plans would most suit your loved one’s needs?
- One Bedroom
- One Bedroom + Den
- Two Bedroom
- Two Bedroom + Den
- No Preference

Are you looking for a rental-based or buy-in community?
- Rental-Based Community
- Buy-In Community

Do you need to sell your home?
- Yes
- No
Will your loved one need to sell their house?
- Yes
- No

Do you still live in your own home?
- Yes
- No
Does your loved one live in their own home?
- Yes
- No

Do you currently receive assistance with daily living activities?
- Yes
- No
Do you provide assistance with daily living activities to your loved one?
- Yes
- No

Is a doctor currently overseeing your care?
- Yes
- No
Is a doctor currently overseeing your loved one’s care?
- Yes
- No

Are you looking for a short-term rehabilitation or extended stay?
- Short-Term Rehabilitation
- Extended Stay

How long do you anticipate your stay will be?
Length of Stay
How long do you anticipate your stay will be?
Length of Stay

Do you currently have Medicare or managed care?
- Medicare
- Managed
Is your loved one currently covered by Medicare or managed care?
- Medicare
- Managed

Do you have a doctor overseeing your care?
- Yes
- No
Has your loved one received a diagnosis of Alzheimer’s or other form of dementia?
- Yes
- No

Are you looking to move immediately?
- Yes
- No
Are you looking to move your loved one immediately?
- Yes
- No

Have you ever lived in or had a respite stay at a memory care community?
- Lived/Living in a Memory Care Community
- Respite Stay Only
Has your loved one ever lived or had a respite stay in a memory care community?
- Lived/Living in a Memory Care Community
- Respite Stay

What amenities are you interested in during your time at Carnegie Village? * Required
- Fine Dining
- Continuing Care Community
- Transportation
- Recreational, Cultural and Social Activities
- Fitness Programs & Gym
- Pool
- Housekeeping Services
- Assistance with Activities of Daily Living
- Medication Management
- Physical Therapy, Speech Therapy or Occupational Therapy
- Rehabilitation Gym

Please give us your contact information.
Name * Required
Email * Required
Phone * Required

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1021 West E Street, Belleville, IL 62220 618-233-2095

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