First Name
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Last Name
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Phone
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Email
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Services Needed
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Companion Care Services: Help with social interactions, meal preparation, errands, laundry, light housekeeping etc
Personal Care Services: Help with mobility, bathing, incontinence
Specialized Care Services: Companion and/or Personal Care Services for clients with Dementia, Parkinson’s, Alzheimer’s, paralysis due to stroke, other severe physical disability
24-Hour or Live-In Care Services: Companion, Personal and Specialized Care Services
Travel Companion Services: Companion of Personal Care Services depending on you or your loved one’s needs
Veteran Care Services: Companion of Personal Care Services for Veterans
Zip code where care services are needed
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How many hours per week would you like care?
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Who needs care? Spouse, parent etc
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How Old is the Person Who Needs Care?
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How Old is the Person Who Needs Care?
0-45
45-54
55-64
65-74
75-84
85 or older
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How many people need care?
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What is the sex of the person who needs care?
What is the sex of the person who needs care?
Male
Female
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