Part I: Who needs care?
Who Needs Care at Home?*
How Old is the Person Who Needs Care?*
Male or Female?*
What is their current living situation?*
Part II: Type of Care
Estimate How Much Care They Might Need*
What Type of Care is Needed? (Check all that apply)*
How will care be paid for?*
Part III: Personal Information
Next Screen, Consent.
Part IV: Consent
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