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
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 the current living situation?
Living alone at home
Living at home with family
In the hospital and needs a sitter
In the hospital and being discharged to home
Assisted living
Independent senior living
Nursing home
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Estimate how much care they might need
A few hours a week
More than 20 hours a week
40 or more hours peer week
Around-the-clock care
Assisted living
Live-in care
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What type of care is needed? (Check all that apply)
Light meal preparation
Light laundry
Light Housekeeping
Companionship
Transportation to appointments
Grocery shopping
Errands
Bathing
Toileting
Medication reminder
Respite care
Hospice support care
Medication administration (RN/LPN)
Diabetes management (RN/LPN)
Tube feeding (RN/LPN)
Wound care (RN/LPN)
Vent/Trach care (RN/LPN)
Injections (RN/LPN)
Ostomy care (RN/LPN)
IV care (RN/LPN)
Infusion therapy (RN/LPN)
Patient and family education (RN/LPN)
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How will care be paid for?
Private funds
Long term care insurance
Medicaid
Other
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What is the zip code where care is needed?
Name of person submitting this form
Email of person submitting this form
Phone number of person submitting this form
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