Care Requirement Form
Who needs care?
*
Myself
Spouse
Parent
Grandparent
Other Relative
Friend
Other
Gender
*
Male
Female
How old is the person who needs care?
*
45-54
75-84
55-64
85 or older
65-74
What is their current living situation
*
Living alone at home
Living at home with family
In the hospital needs a sitter
In the hospital discharging to home
Assisted Living
Independent senior living
Nursing home
How much care they might need?
*
A few hours per week
More than 20 hours per week
40 or more hours per week
Around-the clock care
Live-in care
What type of care is needed? (Check all that apply)
*
Alzheimer's and Dementia Care
Bathing / Showering and grooming assistance
Toileting and Incontinence care
Medication reminders
Light meal preparation
Errands / Shopping / Pharmacy
Light housekeeping
Light laundry
Companionship
Escort on appointments (doctor's office, hair salon, etc)
Safety supervision
Hospice care
Respite care
Other
How will care be paid for?
*
Private funds
Long-term care insurance
Other
Zip code where care is needed.
*
Name of person submitting this form
*
First Name
Last Name
Phone number of person submitting this form
*
-
Area Code
Phone Number
Email address of person submitting this form
example@example.com
Caregiver Preference
Gender
*
Male
Female
Driving?
*
Yes
No
Submit
Should be Empty: