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1
I am a Pennsylvania Resident
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Yes
No
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Yes
No
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2
Who Needs Care?
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Me
Parent
Grandparents
Friend
Other Relative
Other
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Please Select
Me
Parent
Grandparents
Friend
Other Relative
Other
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3
Gender
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Male
Female
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4
How Old is the Person that Needs Care?
Please Select
30-44
45-54
55-64
65-74
75-84
85 or older
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Please Select
30-44
45-54
55-64
65-74
75-84
85 or older
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5
What Type of Care is Needed?
You can select multiple if you need more than one service
- Skilled Nursing
Chronic Disease Management
Diabetic Management
Congestive Heart Failure Management
Infusion Services
Patient/Caregiver Teaching
Ostomy Teaching/Care
Wound Care
Medication Management
- Physical Therapy
Orthopedic Rehab
Cardio-Pulmonary Rehab
Balance/Fall Prevention
- Occupational Therapy
Independence and Self Care Education
Adaptive Equipment Recommendations
Energy Conservation/Daily Living Skills
- Speech Therapy
- Medical Social Work
- Home Health Aides
- Personal Care Services
- Housekeeping Services
- Respite Care Services
- 24 Hour Live-In Care
- Alzheimer’s Care
- Dementia Home Care
Please Select
- Skilled Nursing
Chronic Disease Management
Diabetic Management
Congestive Heart Failure Management
Infusion Services
Patient/Caregiver Teaching
Ostomy Teaching/Care
Wound Care
Medication Management
- Physical Therapy
Orthopedic Rehab
Cardio-Pulmonary Rehab
Balance/Fall Prevention
- Occupational Therapy
Independence and Self Care Education
Adaptive Equipment Recommendations
Energy Conservation/Daily Living Skills
- Speech Therapy
- Medical Social Work
- Home Health Aides
- Personal Care Services
- Housekeeping Services
- Respite Care Services
- 24 Hour Live-In Care
- Alzheimer’s Care
- Dementia Home Care
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6
How will the Care be Paid?
Please Select
Medicaid MCO Insurance
Private Funds
Long-term Care Insurance
Other (Reverse Mortgage, VA Aide & Attendance, etc..)
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Please Select
Medicaid MCO Insurance
Private Funds
Long-term Care Insurance
Other (Reverse Mortgage, VA Aide & Attendance, etc..)
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7
How much Care they need. Just an Estimate.
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Live-In Care
A Few Hours per Week
More or less 20 Hours
More or less 40 Hours
Around the Clock
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Please Select
Live-In Care
A Few Hours per Week
More or less 20 Hours
More or less 40 Hours
Around the Clock
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8
First & Last Name of the person Submitting this Form
First Name
Last Name
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9
What is the current situation of the person who needs care?
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Living at Home with Family
Living at Home Alone
In the Hospital and Staying there
In the Hospital but Discharging to Home
Independent Senior Living
Assisted Living
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Please Select
Living at Home with Family
Living at Home Alone
In the Hospital and Staying there
In the Hospital but Discharging to Home
Independent Senior Living
Assisted Living
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10
City & Zip Code Where Care is Needed
Street Address
Street Address Line 2
City
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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11
E-mail
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example@example.com
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12
Phone Number of the person submitting this form
Please enter a valid phone number.
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13
How did You Hear about Tahara Health?
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14
Any Additional Details or Comments?
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15
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