WHO NEEDS CARE?* Select OneMyselfSpouseParentGrandparentFriendOther
HOW OLD IS THE PERSON WHO NEEDS CARE?* Select One45-5455-6465-7475-8485 OR OLDER
MALE OR FEMALE?* Select OneMaleFemale
WHAT IS THEIR CURRENT LIVING SITUATION?* Select OneLiving home aloneLiving with a family at home
ESTIMATED CARE THEY MIGHT NEED?* Select OneA few hours per week20 or more hours per week40 or more hours per week24 Hours careLive-in care
WHAT TYPE OF CARE IS NEEDED? *(Select all that applies) Meal preparationLaundryLight housekeepingTransporting to appointmentsGrocery shoppingRunning errandsBathingToiletingMedication reminderTransferringIncontinence careGrooming/personal care
HOW WILL CARE BE PAID FOR?* Select OnePrivate fundingLong term care insuranceOther – VA AID and attendance, reverse mortgage, etc
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PHONE NUMBER OF PERSON SUBMITTING FORM.*
