Who Needs Care?*
Parent
Daughter
Son
Spouse
Other Relative
Neighbor/Friend
No elements found. Consider changing the search query.
List is empty.
How Old is the Person Who Needs Care?*
45-54
55-64
65-74
75-84
85 or older
No elements found. Consider changing the search query.
List is empty.
Male or Female?*
Male
Female
No elements found. Consider changing the search query.
List is empty.
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
Assisted Living
Independent Senior Living
Nursing Home
No elements found. Consider changing the search query.
List is empty.
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
No elements found. Consider changing the search query.
List is empty.
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
Respite Care
Alzheimer’s and dementia care
Other
No elements found. Consider changing the search query.
List is empty.
How will care be paid for?*
Private Funds
Long-Term Care Insurance
Veterans Benefits
Medicaid
American Veteran Care Connection
Pennsylvania Independent Waiver Programs
Other
No elements found. Consider changing the search query.
List is empty.
I Agree/Authorize/Consent
SUBMIT THE FORM