Finding the right care for your elderly loved ones can be overwhelming, stressful
and time consuming. Please complete the needs survey below and our responsive
staff will contact you immediately.

Salutation:

First Name:

Last Name:

Zip Code:

Your Phone:

Your Email:

Needs Information

I need services for:

Gender:

Age:

From the list of choices below, which one best describes your primary need:
(Select One)

Eldercare Residence (e.g. assisted living, nursing home, senior community)
Home Services (e.g. Light Housekeeping, Meal Preparation, Shopping)
Home Services including Personal Care (e.g. Bathing and Toileting)

Please select your preference for where care is to be provided.
(Select all that apply)

In-Home

Adult Day Care Facility

Independent Living

Residential Care Home

Assisted Living Facility

Skilled Nursing

Please select any services that that you believe are required for the Care Recipient:
(Select all that apply)

Companion Services

Hospice Services

Healthcare (non-medical)

Live In Home Care

Healthcare (medical)

Transportation (Non-Medical)

Homemaker Services

Personal Care (e.g. Bathing and Toileting)

Light Housekeeping

Assist with Ambulation

When would you like services to begin?
(Select One)

Immediately
Within 1 Week
Within 2 Weeks
Within 4 Weeks
Within 8 Weeks

Please indicate the number of hours of support services that you estimate the care recipient requires.
(Select One)

More than 100 hours per week
40 to 100 hours per week
20 to 40 hours per week
10 to 20 hours per week
1 to 10 hours per week

Which of the following best describes the care recipient's current living arrangement?
(Select One)

At home and living independently
At home with some services
Assisted Living Facility
Skilled Nursing Facility
Hospital

What funding source will the primary payer use for services? (Select One)

Private pay

Medicare

Medicaid

Long Term Care Insurance

Combination (Private Pay & Other)

Many eldercare services and products are not covered by insurance, Medicare or Medicaid. Are you willing to pay "out-of-pocket" for required services?

Yes
No

How much have you budgeted for these "out-of-pocket" expenses?
(Select One)

Less than $250 per week	$1,000 to $1,500 per week
$250 to $500 per week	Over $1,500 Per week
$500 to $1,000 per week

How would you describe the care recipients feeling about receiving assistance?
(Select One)

Very Receptive
Somewhat Receptive
Resistant to Help
Unaware

Please include any additional information that you think may prove helpful.