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Disclosure & Acknowledgment Form

Making the senior care process simple, transparent, and stress-free is at the heart of what we do. Review this form to understand how our placement services work, what you can expect, and how we support you through the entire journey.

Our goal is to keep everything clear and upfront so you always know exactly where you stand—no confusion, no pressure, and no hidden commitments.

Why This Form Matters

How our no-cost placement services work
What information we use to help guide your senior care search
How we communicate with you and potential communities
Your acknowledgment that we are acting as your placement provider
The support you can expect from our team throughout the process

2040 S. Alma School Rd. Ste 1, Chandler, AZ 85286

Senior Placement Advisors – Disclosure & Acknowledgment Form

Services We Provide

Senior Placement Advisors assists seniors and their families in identifying housing options including Care Homes, Independent Living, Assisted Living, Memory Care Communities, and other senior living solutions.

We will: Gather pertinent information to identify the best care options for you and/or your loved one (e.g., care needs, finances, location, lifestyle, dining, pets). Verify provider records with state agencies such as theArizona Department of Health Services. Present a list of prescreened communities that best meet your needs.Schedule tours on your behalf—or provide contact information if you prefer to schedule yourself. Accompany you or your loved one on tours to provide advocacy and guidance (if desired).

Arizona Law Disclosure (Pursuant to A.R.S. § 36-446.14)

Arizona law requires us to provide the following information:

Nature of Our Business: We refer residents to independent living, assisted living communities, and assisted living homes.
Compensation: If you and/or your loved one move into a community or home we refer you to, we are paid by that community or home. Our referral fees typically range from 50% to 100% of the first month's rent and care charges.
No Conflicts of Interest: We have no ownership, control, financial, management, or familial relationship with any of the facilities or homes to which we make referrals.
Your Right to Terminate Services: You may end our services at any time by written or electronic notice. If you terminate services, we will stop using and destroy any of your personal information. If you terminate services, we will not be entitled to any fee for any move-in you make after the date of the termination notice.

Acknowledgment & Authorization

By signing or checking the box below, you confirm that you have received and reviewed this Disclosure Statement and you are either: the Client with medical power of attorney, or spouse as an authorized representative; or a family member/legal representative (with Power of Attorney or Guardianship).

You authorize Senior Placement Advisors and its representatives to communicate with potential senior living providers on your behalf.

Client Confirmation

Provide your legal details and draw your signature. A PDF mirroring this disclosure will be generated and stored securely once you submit.

First Name

Last Name

Phone Number

Date

Relationship to Client (if applicable)

Signature

I confirm I have reviewed the Disclosure Statement and authorize the team to coordinate with senior living providers on my behalf.

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