Ready When You AreWe’re here to answer questions and walk you through next steps—fill in the info and we’ll be in touch! Name * First Name Last Name Email * Phone * (###) ### #### Preferred Method of Contact * Phone Email Either Who is this inquiry for? Myself Family Member Other Name of Prospective Resident Optional if Same First Name Last Name Age of Prospective Resident Level of Care Needed Check all that apply Assistance with Daily Activities Dementia/Memory Care Hospice Care Bedridden Care TBI Care SCI Care Mental Health Support Developmental/Physical Disabilities Support Where does the prospective resident currently live? Home Hospital Another facility Other When are you looking to move or begin care? Immediately Within 1 month 1-3 Months Just gathering information What is your estimated monthly budget for care? Under $4,500 $4,500 - $6,500 $6,500 - $8,500 $8,500+ Preferred Day(s) for a Tour * Check all that apply Monday Tuesday Wednesday Thursday Friday Saturday Sunday Preferred Time of Day * Morning (9am-12pm) Afternoon (12pm-4pm) Evening (4pm-8pm) Any additional information, preferences, or questions? Optional By submitting this form, you agree to our Privacy Policy and Terms of Service. Your information will be kept confidential. Thank you for reaching out to Khan Care!We’ve received your information and will be in touch shortly to answer your questions or discuss the next steps. We’re honored you’re considering us and look forward to connecting with you soon.If you’d like to speak with someone right away, feel free to call us at (310) 845-6339
