Who Needs Care?
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Who Needs Care?
Myself
Spouse
Parent
Son
Daughter
Grandparent
Other Relative
Friend
Other
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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
Pediatric Care
Other
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How will care be paid for?
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How will care be paid for?
Private Pay
Private Insurance
Long-Term Care Insurance
Workers' Comp Insurance
Medical Insurance Plan (Not all are accepted)
Maryland Medicaid Program
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First Name
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Last Name
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Email
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Phone
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Zipcode
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