Who Needs Care?*
Parent
Daughter
Son
Spouse
Other Relative
Neighbor/Friend
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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?*
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
Live-In Care
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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
Skilled Nursing
Companionship
Escort on appointments (doctor’s office, hair salon, etc)
Safety Supervision
Hospice Care
Respite Care
Alzheimer’s and dementia care
Client Advocacy
Additional Family Services
Snowbird Service
Healthcare Staffing
Other
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How will care be paid for?*
Private Funds
Long-Term Care Insurance
Veterans Benefits
Medicaid
Veterans Administration
Indemnity Plans
Health Maintenance Organizations (HMOs)
Preferred Provider Organizations (PPOs)
Medicare Managed Care Organizations (MCOs)
Workers Compensation
Blue Cross Blue Shield
Other
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I Agree/Authorize/Consent
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