Getting Started
I am an North Carolina Resident
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Please Select
Yes
No
Who Needs Care at Home?
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Please Select
Self
Parent
Grandparent
Other Relative
Friend
Other
How Old is the Person Who Needs Care?
*
Please Select
45-54
55-64
65-74
75-84
85-older
Male or Female?
*
Please Select
Male
Female
What is their current living situation?
*
Please Select
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
Estimate How Much Care They Might Need
*
Please Select
A few hours per week
More than 20 hours per week
40 or more hours per week
Around-the Clock Care
How will care be paid for?
*
Please Select
Private Funds
Long-Term Care Insurance
Other - (VA Aid and Attendance, Reverse Mortgage, ect)
What type of Care is Needed? (Check all that apply)
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Light Meal Preparation
Light Laundry
Light Housekeeping
Companionship
Transportation to Appointments
Grocery Shopping
Errands
Bathing
Toileiting
Medication Reminders
Respite Care
Hospice
Zip Code Where Care is Needed
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Name of Person Submitting this Form
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First Name
Last Name
Your Email Address - We will send you information via email
*
example@example.com
Phone Number of Person Submitting this Form
*
Please enter a valid phone number.
Format: (000) 000-0000.
Additional Comments or Information
Submit
Should be Empty: