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Clear View Senior Solutions Intake Form
 Please answer the following questions to the best of your knowledge. We use this information to ensure we are capturing all potential discounts available and not miss hidden expenses.
Family Member  Name *
Senior  Name  *
What is your relationship to the Senior? *
What is the main reason you are contacting CVSS? *
Required
How did you hear about CVSS?  *
If referral please let us know who to thank: 
Family member Email *
Family Member Address *
Family Member Phone number
Senior Address *
Senior Phone number
Senior Email *
Senior Birthday or Age 
What is relationship status of Senior
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Is Senior currently living in own home?
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If Yes, do they live alone or with someone?
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If Yes, Is there an HOA for their neighborhood?
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If yes, check all services established
If no to living in their own home, what type of establishment are they in?
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How are most bills paid? *
Is Senior a veteran? *
What was Senior's occupation before retirement? *
Check any that has been established *
Required
Do you have any concerns about Memory Loss/Dementia?  *
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