I Don't See My City Use Form Below for Info & Pricing Or Call (631) 319-3961 Who Needs Care at Home?*Select OneMyselfSpouseParentGrandparentOther RelativeFriendOtherHow Old is the Person Who Needs Care?*Select One45-5455-6465-7475-8485 or olderMale or Female?*Select OneMaleFemaleWhat is their current living situation?*Select OneLiving Alone at HomeLiving at Home with FamilyIn the Hospital Needs a SitterIn the Hospital Discharging to HomeAssisted LivingIndependent Senior LivingNursing HomeEstimate How Much Care They Might Need*Select OneA few hours per weekMore than 20 hours per week40 or more hours per weekAround-the-Clock CareLive-In CareWhat Type of Care is Needed? (Check all that apply)* Light Meal Preparation Light Laundry Light Housekeeping Companionship Transportation to Appointments Grocery Shopping Errands Bathing Toileting Medication Reminders Respite Care Hospice How will care be paid for?* Private Funds Long-Term Care Insurance Medicaid Other - (VA Aid and Attendance, Reverse Mortgage, etc) Many Senior In-Home Care services and products are not covered by insurance, Medicare, Medicaid or public assistance. Most individuals and families often need to pay "out-of-pocket" for some or all services requested. Are there other sources of financing available to you, such as Social Security benefits, VA benefits, or Private Funds?* Yes No I don't know How did you hear about us?*Zip Code Where Care is Needed*Name of Person Submitting this Form* First Last Your Email Address- We will send you information via email.* Phone Number of Person Submitting this Form*
