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Reason for contacting us*
I need assistance for myself.
I am seeking assistance for someone else.
I am a professional seeking more information about your company.
I am seeking assistance for:
A Parent
An In-Law
My Spouse
My Grandparent
My Child
A Sibling
A Friend
Other
If other:
Name of Person Needing Assistance
Postal Code of the Person Needing Assistance
Individual needing care lives:
alone
with spouse
with caregiver
independently in senior housing
in assisted living facility
in hospice
in hospital
other
Other type of living arrangement:
What medical conditions are they living with:
ALS
Alzheimer's / Dementia
Arthritis
Cancer
Coronary Disease
Depression
Diabetes
Hearing Impairment
Incontinence
Multiple Sclerosis
Osteoporosis
Parkinson's
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Stroke
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Vision Impairment or disease
Other medical conditions:
How will care be financed?
Private pay by client
Private pay by client's loved ones
Long term care insurance
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Medicaid
Other:
Are you or a family member a veteran or a surviving spouse?
Yes
No
How often do you anticipate needing care?
Number of days a week:
1
2
3
4
5
6
7
Number of hours a day:
Other:
When do you anticipate service to begin?
Immediately
Next week
Next month
Sometime within the next 6 months
In conjunction with a planned event or procedure
Planned Start Date:
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