First Name Of Person Submitting This Form
Last Name Of Person Submitting This Form
Email
*
Phone
*
Full Name
Who Needs Care At Home?
Myself
Parent
Grandparent
Other Relative
Friend
Other...
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How Old Is The person Who Needs Care?
45-54
55-64
65-74
75-84
84 and older
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Male or Female?
Male
Female
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What Is Their Current Living Situation?
Living At Home
Living At Home With Family
In The Hospital, Needs A Sitter
In The Hospital Discharging To Home
Assisted Living
Independent Senior Living
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Estimate How Much Care They Might Need?
A Few Hours Per Week
More Than 20 Hours Per Week
40 Hours or More Per Week
Around The Clock Care
Live In Care
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What Type Of Care Is Needed? (Check All That Apply)
Companionship
Errands
Light Meal Prep
Light Housekeeping
Light Laundry
Bathing
Toileting
Medical Reminders
Grocery Shopping
Transportation to Appointments
Respite Care
Hospice
How Will Care Be paid For?
Private Funds
Long Term Care Insurance
Medicaid
Other (VA Aid and Attendance, Reverse Mortgage, Etc)
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Additional Comments or Information
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