Who Should We Contact to Answer Questions?

Tell Us About the Person Who Might Need Care.

Who Needs Care?

Myself
Spouse
Parent
Grandparent
Other Relative
Friend
Other
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How Old is the Person That Needs Care?

45-54
55-64
65-74
75-84
85 and Older
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Is the Person Male or Female?

Male
Female
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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.

A Few Hours Per Week
More Than 20 Hours Per Week
40 or More Hours Per Week
Around-the-Clock Care
Unknown
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How Will the Care Be Paid For?

Private Funds
Long-Term Care Insurance
Veteran Benefits
TSOA
Medicaid
Other
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What Type of Care is Needed? (Check All that Apply)

Bathing/Showering & Grooming Assistance
Toileting & Incontinence Care
Medication Reminders
Light Meal Preparation
Errands/Shopping/Pharmacy
Light Housekeeping
Light Laundry
Companionship
Escort on Appointments (Doctors, Hair Appointments, etc.)
Safety Supervision
Respite Care
Alzheimer's & Dementia Care
Other
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