The Golden Journey

Fill out the form, or call us right now and Let Us Help
Phone: 805-526-0938 Fax: 805-526-0938
Email: cay@mygoldenjourney.com
OR
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Embark on the GOLDEN JOURNEY

Welcome to The Golden Journey, and thank you for visiting our website.
Whether it's housing, homecare, private nursing, or other services you or someone you care about may need, we'll do the work and help you find what you are looking for.

We'll research the facilities and agencies in your area and can provide you with a comparison report containing important points of evaluation, such as location, services and pricing, to name just a few. With our research, you'll have the information you need to make this crucial decision. We can even arrange tours for each facility, allowing you to concentrate on the choices available to you.*
*Available in most California areas

Best of all, many of our standard services are free to our clients, so getting started is just a click away.

Please take a few minutes to provide us with some preliminary information, then click the HELP ME NOW button to get started. OR, if you prefer, check this box if you would rather have someone contact you to help you with this information, OR, feel free to
contact us at: 805-526-0938 or cay@mygoldenjourney.com

Contact Information: (* denotes required information)

Please provide us with information about you:
Salutations:
* First Name:		* Last Name:
City:
* State:		* Zip Code:
* Phone:		Cell No.:
* Email:		Fax:
How do you wish to be contacted:
What is the best time to contact you?

Please provide us with information on your elderly loved one:
* First Name:		* Last Name:
* City:
* County:
* State:		* Zip Code:
* Birthday:	Month Day: Year	* Age:
* Gender:		* Relationship:

Please list at least 3 cities nearby the city services are needed:

Needs Information:

Home Care Services - Services Requested (Please check all that apply)

	Companionship
	Errands
	Laundry
	Light Housekeeping

Approximately how many hours per day and how many days per week are you anticipating?

	Meal Preparation
	Shopping
	Others (Please list other services you are looking for

Home Healthcare Services - Services Requested (Please check all that apply)

	Bathing		Hygiene Assistance
	Dressing		Medical Assistance
	Feeding		Medication Monitoring/Disbursement
	Grooming		Toileting

Approximately how many hours per day and how many days per week are you anticipating?

	Transferring
	Walking
	Others (Please list other services you are looking for

Alternative Housing (Please check all that apply)

Board and Care/Residential Care Facility
Assisted Living Facilities/Alzheimer's/Dementia Care Specialty
Senior Apartment Living/Independent Living
Continuing Care Communities
Skilled Nursing Facilities
Other (Please list other services you are looking for)

Private Nursing (In-Home, at alternative location)

Please tell us about the current living situation of your elderly loved one.

Lives at home - independent

Lives at home - receiving some assistance

Lives at a Board & Care/RCFE

Lives at an Assisted Living Facility

Lives at a Senior Apartment complex

Resides at a Skilled Nursing Facility

Lives with a relative or friend

Please tell us what source of funding will be used for paying for care and/or housing. (Please check all that apply)

Private Pay

Medicare

Medicaid (state assistance)

Insurance (ie, Long Term Care)

Yes No

Does your loved one receive any income? (Social Security, SSI, retirement, pension IRAs, Investments)

If yes, approximately how much? $

Yes No

Is he/she a veteran?

What is the approximate budget you have estimated for private-pay expenses?

Please check any/all health conditions/issues that currently relate to your elderly loved one.

Alzheimer's	Hearing Problems	Parkinsons
Arthritis	Heart/Cardiac Disease	Pulmonary/Breathing
Dementia	High Blood Pressure	Stroke
Depression	Incontinence	Vision/Eye Problems
Diabetes	Memory Concerns	Others
Dialysis	Osteoporosis

	ADLs (Activities of Daily Living)
	Bathing	Toileting
	Dressing	Transferring
	Grooming	Walking

Please tell us how soon the services will be needed?

How did you hear about us?

Brochure

Internet

Phone Book - Yellow Pages

Phone Book - White Pages

Referral - Name:

Comments and Questions:

Required Fields marked with *