Senior Living Placement Referral Form

Earn a $500 Credit!

Refer a current or prospective client in need of senior living and receive a $500 credit when your referral successfully becomes a client of Happy Quest.

First Name

Last Name

Who is the contact?

Care recipient Family/friend of care recipient

Contact Email

Phone

Zip code for care

Care Needs

Why Does the Care Recipient Need Senior Living / Community Care?*
(Brief description of care needs, diagnosis, safety concerns, discharge planning, etc.)

Client Approval Confirmation

Before we can process your referral, we must confirm that the client has agreed to be referred to Happy Quest Home Care's Senior Living Placement Program.

I have confirmed that the Client agrees to be referred. I have NOT confirmed whether the Client agrees to be referred and understand that a referral cannot be made until the Client agrees.

💰 Referral Reward

You will receive a $500 billing credit once your referral successfully moves into a Happy Quest partner senior living community and all placement conditions are met.

📌Important Notice

Once submitted, the referred contact will be contacted by a Happy Quest Senior Living Placement Advisor shortly.