Your First Name
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Your Last Name
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Your Email
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Your Cell Phone
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Tell us About the Person Who Needs Care.
Who Needs Care?
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Who Needs Care?
Parent
Daughter
Son
Spouse
Other Relative
Neighbor/Friend
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Zip Code of the person who needs care
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What Type of Care is Needed? (Check all that apply)
What Type of Care is Needed? (Check all that apply)
Skilled Nursing
Physical Therapy
Occupational Therapy
Speech Therapy
Medical Social Work
Home Health Aide
Wound Care
Ostomy Care
Specialty Programs
Other
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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 Discharging to Home
Assisted Living
Independent Senior Living
Nursing Home
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How Old is the Person Who Needs Care?
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How Old is the Person Who Needs Care?
45-54
55-64
65-74
75-84
85 or older
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How will care be paid for?
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How will care be paid for?
Traditional Medicare
Medicare Advantage Plans (AETNA and United Healthcare)
Other
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How Did You Hear About Us?
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How Did You Hear About Us?
Referred By a Friend/ Colleague
Referred By a Professional
Internet Search
Facebook
Other Social Media
Newsletter/ Email
Other Advertising
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Would you like to receive texts? Yes or No?
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Yes, I would like to receive texts.
No, I do not want to receive texts.
I agree/authorize/consent
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I Agree/Authorize/Consent
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