* Required Information
Who Needs Care at Home?
*
Select One
Myself
Spouse
Parent
Grandparent
Other Relative
Friend
Other
How Old is the Person Who Needs Care?
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Select One
45-54
55-64
65-74
75-84
85 or older
Male or Female?
*
Select One
Male
Female
What is their current living situation?
*
Select One
Living Alone at Home
Living at Home with Family
In the Hospital Needs a Sitter
In the Hospital Discharging to Home
Assisted Living
Independent Senior Living
Nursing Home
Estimate How Much Care They Might Need
*
Select One
A few hours per week
More than 20 hours per week
40 or more hours per week
Around-the-Clock Care
Live-In Care
What Type of Care is Needed? (Check all that apply)
*
Light Meal Preparation
Light Laundry
Light Housekeeping
Companionship
Transportation to Appointments
Grocery Shopping
Errands
Bathing
Toileting
Medication Reminders
Respite Care
Hospice
How will care be paid for?
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Private Funds
Long-Term Care Insurance
Medicaid
Other - (VA Aid and Attendance, Reverse Mortgage, etc)
Many Senior In-Home Care services and products are not covered by insurance, Medicare, Medicaid or public assistance. Most individuals and families often need to pay "out-of-pocket" for some or all services requested. Are there other sources of financing available to you, such as Social Security benefits, VA benefits, or Private Funds?
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Yes
No
I don't know
Zip Code Where Care is Needed
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Name of Person Submitting this Form
First
*
Last
*
Your Email Address - We will send you information via email
*
Phone Number of Person Submitting this Form
*