Zip Code of the Person Who Needs Care
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Who Needs Care at Home?
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Who Needs Care at Home?
Myself
Spouse
Parent
Grandparent
Other Relative
Friend
Other
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Gender
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Gender
Male
Female
Other
Prefer not to answer
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Age
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How old is the person who needs care?
18-39
40-50
51-60
61-70
71-80
81-90
90+
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What is their current living situation?
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What is their current living situation?
Living Alone at Home
Living at Home with Family
In the Hospital, Needs a Sitter
In the Hospital, Discharging to Home
Independent Senior Living
Assisted Living
Memory Care
Skilled Nursing Facility
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Estimate How Much Care They Might Need
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Estimate How Much Care They Might Need
A few hours per week
More than 20 hours per week
40 or more hours per week
Around-the-Clock Care
Live-In Care
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What Type of Care is Needed? (Check all that apply)
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What Type of Care is Needed? (Check all that apply)
Bathing/Showering and grooming assistance
Toileting and incontinence care
Medication reminders
Light meal preparation
Errands/Shopping/Pharmacy
Light housekeeping
Light laundry
Companionship
Escort on appointments (doctor’s office, hair salon, etc)
Safety Supervision
Hospice Care
Respite Care
Alzheimer’s and dementia care
Other
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How will care be paid for?
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How will care be paid for?
Private Funds
Long-Term Care Insurance
Other
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Your First Name
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Your Last Name
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Your Email
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Your Phone
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How did you hear about us?
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I Agree/Authorize/Consent
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