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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Your First Name
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Your Last Name
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Does the loved one live in Lincoln, NE, or within Lancaster County?
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Yes
No
Not Sure
Zip code of the person who needs care
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Phone
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Email
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What prompts the need for Senior Home Care? (Check all that apply)
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What prompts the need for Senior Home Care? (Check all that apply)
Continue to age-in-place - longer - in the current residence/home
Recovery Care (Support was prompted by a health change)
Parkinson’s Management
Dementia/Memory Care
Bring Assisted Living Home
Stroke Recovery
Hospice/Palliative Care
Fall Risk
Other
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When is the care need greatest?
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When is the care need greatest?
Morning
Afternoon
Evening
Overnight
24/7 Care
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Does the loved one have a Long Term Care Insurance Policy?
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Yes
No
Not Sure
How Did You Hear About Us?
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How Did You Hear About Us?
Hospital
Healthcare Provider
Other
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I agree/authorize/consent
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I Agree/Authorize/Consent
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