Take Our Pre-Assessment Name* First Last Email* Phone*Place of service (i.e. own home, apt, assisted living, etc)City where services will be providedWhat is the best time to contact you?MondayTuesdayWednesdayThursdayFridaySaturdaySundayTimeWho are you Inquiring About Care?ParentSiblingSpouseExtended FamilyFriendYourselfDischarge PatientOtherIs this personMaleFemaleHave you / they had home care before now?YesNoDo you plan on utilizing service throughLong Term Care InsuranceVeteran Approved BenefitsMedicaid / Public ReliefPrivate PayUnsure. Please assist with optionsHow soon do you intend on starting service?ImmediatelyWithin 30 daysWithin 30 - 90 daysWithin a yearNot sure, just looking at resourcesHow much daily care is needed?Short Visit (3-4 hours/day)Standard Visit (4-8 hours/day)Overnight Visit (8pm - 8am)Live-in (24 hours)Which types of non-medical caregiver services will help you? Personal Care Services (grooming, bathing, dressing, toileting, assistance with active range of motion activities & more) Senior Companion Care Services (conversation, reading, games, friend visits, appointments & more) Homemaking Care Services (meal planning, prep & cooking, light housekeeping, organization, laundry / linens, errands, grocery shopping, transportation & more) Personal Assistance & Supportive Care (medication reminders and assistance with self-administered medication, record food intake, limit or encourage fluids, fall prevention, safety & more) Which days will care be needed? Monday Tuesday Wednesday Thursday Friday Saturday Sunday Is there any other information that could help us better understand what you are looking for, or the person you are calling about?May we have your permission to send them/provide information, free resources, tips and advice for Long Term Care planning? We will not share or sell your email to 3rd parties sources.YesNo
