Zip Code Where Care is Needed?
Zip Code
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Who Needs Care?
Who Needs Care?
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Who Needs Care?
Myself
Spouse
Parent
Grandparent
Other Relative
Friend or Neighbor
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List is empty.
How Old is the Person Who Needs Care?
How Old is the Person Who Needs Care?
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How Old is the Person Who Needs Care?
40-50
51-60
61-70
71-80
81-90
91+
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How Many Hours of Care Per Week is Needed? (Estimate)
How Many Hours of Care Per Week is Needed? (Estimate)
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How Many Hours of Care Per Week is Needed? (Estimate)
Minimal Care (10 hours or less per week)
Basic Care (20 hours or less per week)
Daily Care (20+ hours per week)
Full-Time Care (40+ hours per week)
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What Type of Care is Needed?
What Type of Care is Needed? (Select all that apply)
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Companionship
Errands
Light Housekeeping
Light Laundry
Meal Preparation
Grocery Shopping
Transportation
Medication Reminders
Appointment Reminders
Respite Care
Hospice Care
Alzheimer's / Dementia Care
Bathing and Dressing
Toileting Assistance
How Do You Plan on Paying for Home Care?
How Do You Plan on Paying for Home Care?
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Private Funds
Long-Term Care Insurance
Reverse Mortgage Proceeds
Life Settlement Proceeds
Medicare
Medicaid
Other
I Have No Idea
You Are Almost Done!
All We Need is Your Contact Information.
First Name
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Last Name
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Email
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Phone
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Choose all that apply.
How Would You Like To Be Reached?
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Email
Phone
Text
Best Time to be Reached?
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Anytime
Mornings
Afternoons
Evenings
I understand that by entering my information, I will be receiving a call and emails from a staff member of Caring At Heart by email, phone or text. I understand that my information is safe and is not sold or shared with 3rd parties.
Consent for Contact
*
I Agree/Authorize/Consent