Who Needs Care?
*
Myself
Parent
Other Relative
Spouse
Grandparent
Friend
Other
How Old is the Person Who Needs Care?
*
45-54
55-64
65-74
75-84
85-94
Over 95
Male or Female
*
Male
Female
What is their current living situation?
*
Living Alone at Home
In the Hospital, Needs a Sitter
Assisted Living
Nursing Home
Living at Home with Family
In the Hospital Discharging to Home
Independent Senior Living
Estimate How Much Care they Might Need
*
A few hours per week
40 or more hours per week
Live-In Care
Living at Home with Family
Around-the-Clock Care
What Type of Care is Needed?
*
Light Meal Preparation
Light Housekeeping
Transportation to Appointments
Errands
Toileting
Respite Care
Light Laundry
Companionship
Grocery Shopping
Bathing
Medication Reminders
Hospice
How will care be paid for?
*
Private Funds
Medicaid
Long-Term Care Insurance
Other - (VA Aid and Attendance, Reverse Mortgage, etc.)
Are there other sources of financing available top you, such as Social Security Benefits, VA benefits, or Private Funds?
*
Yes
No
I don't know
Name of Person Submitting this Form
*
Your Email Address
*
Your Phone Number
*
Other Comments of Messages
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