Survey Form

CONFIDENTIAL : YOUR INFORMATION IS PRIVATE AND WILL NOT BE SHARED WITH ANYONE OUTSIDE THE LEELA SENIOR LIVING DEVELOPMENT TEAM

All the fields marked asterisk (*) are required.

FirstName*

Please type your first name.

MiddleName

Please type your middle name.

LastName*

Please type your last name.

Spouse FirstName

Please type your spouse first name.

Spouse MiddleName

Please type your spouse middle name.

Spouse LastName

Please type your spouse last name.

E-mail*

Please type your email address.

Secondary E-mail

Please type your secondary email address.

Contact Number*

Please type your contact number.

Secondary Contact Number

Please type your secondary contact number.

Street

Please type your street address.

City

Please type your city.

State

Please type your state.

Zip Code

Please type your zip code.

I am*

Working

Retiring Soon

Retired

Please select working option.

My Spouse is

Working

Retiring Soon

Retired

Please select spouse working option.

Age Range*

55-60

65-70

75-80

80+

Please select age range.

Preferred Location*

Sugarland / Richmond / Rosenberg / Southwest Area

Katy / West Houston / Hwy 6 -I-10 Area

Pearland / Clear Lake / Nasa area

Woodlands / Spring / Cypress / 249 area

Other

Please select your preferred location.

Other Location*

Please provide other preferred location description.

Timing : Please tell us about your readiness to make a decision on moving into a retirement community.*

I'm Ready Now

I'll Be ready within, 1-2 years

I'll Be ready within, 3 to 4 years

I'll Be ready within, 5 yrs

Please select your readiness timing.

Tell us a little bit about the Retirement home you would prefer to live in.

I Prefer to*

Own

Rent

Please select your preferred option.

Home Style*

Single Story

2 Story

No Preference

Please select your home style.

Home Type*

Cottage Style Home with Yard

Semi-Detached Home with Shared Yard

Apartment Style Living

Assisted Living Home|

Please select your home type.

Other Bedrooms*

Please describe your bedrooms requirement.

Bathrooms*

1 Bathroom

2 Bathrooms

3 Bathrooms

Other

Please select bathroom options.

Other Bathrooms*

Please describe your bathrooms requirement.

Shower Or Tub?*

Shower

Tub

Desi Bath

Other

Please select shower or tub options.

Other Shower or Tub*

Please describe your shower or tub requirement.

I also Need*

Home Office

Prayer Room

Game Room

Other

Please select extra home options.

Other Home Requirements*

Please describe your home requirement.

I Prefer My Home to be designed according to Vastu Architecture Principles.*

Yes

No

No Preference

Please select VAstu Architecture option.

I would like to Volunteer my time and expertise to help make Leela Senior Living Community a Reality.

Yes

No

No Preference

Please select Volunteering option.

Other Occupation*

Please describe your occupation.

Comments

Please comment here.

Terms & Conditions*

BY SUBMITTING THIS SURVEY, I UNDERSTAND THAT LEELA SENIOR LIVING COMMUNITIES MAY CONTACT ME FROM TIME TO TIME WITH UPDATES AND QUESTIONS ABOUT THE PROPOSED SENIOR LIVING RETIREMENT COMMUNITY. - LEELA SENIOR LIVING WILL NEVER SELL MY INFORMATION OR PUBLISH IT IN ANY MARKETING MATERIAL WITHOUT MY CONSENT. Please select the terms & conditions.

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