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Telecommunications
PHONE: 310.204.2223
FAX: 310.202.0497

Email Address
Information: Info@heartlightonline.com
Webmaster: Webmaster@mjbconsulting.com

Mailing Address
Heart Light
3765 Motor #600
Los Angeles, CA 90034

Use the following form to contact us:

Please fill out this form to the best of your ability. Required Items are shown in Red. After this form is received by Heart Light a Care Counselor will contact you.

Your Contact Information
Your First Name:
Your Last Name:
Your Address:
City:
State:
Zip:
Second Contact:
Second Contact - Relationship to Senior:
Home Phone Number (please provide at least one phone contact number):
Business Number:
Cell Phone:
Fax:
Email Address:
What is your relationship to the senior?:
Senior's Information
Senior's First Name:
Senior's Last name:
Sex:
 female male
Age:
Date of Birth:
If this is a couple Name of Second Person:
Sex:
 female male
Age:
Date of Birth:
Presently living where?
 Home With Relatives Facility
If presently living at facility,
please indicate name:
Diagnosis:
Heart disease Alzheimer’s Disease 
Stroke  Parkinson’s Disease
Emphysema Mental Illness
Dementia Diabetic
TIA’s  Depression
Healthy  Multiple Sclerosis
Congestive Heart Disease
Macular Degeneration   
Short Term Memory Loss  
Other?
Assistance needed:
Bathing Walking 
Dressing  Injections
Medications Catheter 
Incontinence Colostomy  
Toileting  Feeding 
None   Self Sufficient  
Fill in the following if applicable:
Self Sufficient Oxygen     
Forgetful Wanderer 
Confused  Tube Feeding 
Cane IV 
Walker Aphasia
Wheelchair  Smoker   
Electric cart Pets     
Bedridden       
Blind      
Partially Sighted    
Deaf      
Hard of Hearing   
Additional Information
What type of Facilities are you looking for:
Type of Room Desired?:
What is the monthly budget?
(Select from drop down list
or fill in amount)

Location
Location Desired(city)?:
Zip Code
Radius of miles from Zip
How soon do you need placement?
How did you hear about Heart Light?
Other?
May a facility contact you for questions?
 yes no
May a facility send you a brochure?
 yes no
To best serve you, please indicate any facilities you have seen or contacted to avoid duplication
Additional Information or Comments



 

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