Who Needs Care?
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Who Needs Care?
Myself
Spouse
Parent
Grandparent
Other Relative
Friend
Other
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Zip Code of the Person WHO NEEDS CARE.
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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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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
Assisted Living
Independent Senior Living
Nursing Home
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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)
Personal Care- Bathing, Grooming, Toileting, Dressing
Companionship
Incontinence Care
Medication reminders
Light meal preparation
Errands/Shopping/Pharmacy
Light housekeeping
Light laundry
Escort on appointments (doctor’s office, hair salon, etc)
Safety Supervision
Hospice Care (End of Life Care)
Respite Care (A Break for the Family Caregiver)
Alzheimer’s or Dementia Care / Memory Loss
Skilled Nursing Care at Home
Physical Therapy at Home
Occupational Therapy at Home
Speech Therapy at Home
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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How will care be paid for?
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How will care be paid for?
Private Funds
Long-Term Care Insurance
Veterans Benefits
Private Insurance (Private Health Insurance Does Not Pay for Companion Care at Home)
Medicare (Medicare Does Not Pay for Companion Care at Home)
Medicaid
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 Cell Phone
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I understand that by entering my information, I will be receiving a call and emails from a staff member of a local home care agency. I will receive a list of recommended home care agencies based on my answers and the zip code of the person who needs care.
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