Part I: Who needs care?

Who Needs Care at Home?

Myself
Spouse
Parent
Grandparent
Other Relative
Friend
Other
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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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Part II: Type of Care

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
Companionship
Escort on appointments (doctor’s office, hair salon, etc)
Safety Supervision
Hospice Care
Respite Care
Alzheimer’s and dementia care
Other
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How will care be paid for?

Private Funds
Long-Term Care Insurance
Other
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Part III: Personal Information

Next Screen, Consent.

Part IV: Consent

I understand that by entering my information, I will be receiving a call and emails from a staff member of Universal Home Care.

I agree to the privacy policy. (Bottom of Page)

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