Who Needs Care?
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Who Needs Care?
Daughter
Son
Spouse
Other Relative
Neighbor/Friend
Professional Referral Source
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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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Male or Female?
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Male or Female?
Male
Female
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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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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
Skilled Nursing
Respite Care
Alzheimer’s and dementia care
Physical Therapy
Occupational Therapy
Speech Therapy
Medical Social Work
Home Health Aides
Wound/Ostomy Care
Specialty Programs
Other
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How will care be paid for?
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How will care be paid for?
Medicare
AETNA
United Healthcare
Other
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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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I agree/authorize/consent
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I Agree/Authorize/Consent
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