Are you or your loved one over 60 and reside in Licking County?
If so, give us a little information and we can recommend services.
Name
First Name
Last Name
Email
example@example.com
How old are you/loved one?
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What is your/loved ones current living situation?
Please Select
At home independently
At home but needs some help
Living with family
Assisted Living
Hospital, Rehab (Temporary Stay)
Which best describes your/loved ones day-to-day ability
Please Select
Fully independent
Some difficulty with tasks (cleaning, cooking, errands)
Needs regular help with personal care
Mostly homebound
Unable to leave home without assistance
What is the biggest challenge right now? (Select up to 2–3)
Getting meals / nutrition
Transportation
Loneliness / isolation
Household tasks
Personal care (bathing, dressing)
Managing health / appointments
Technology / staying connected
Caregiver support / burnout
Just looking for things to do / stay active
Are you/loved one able to leave the home?
Please Select
Yes, independently
Yes, but need transportation
Rarely leave home
No, homebound
How socially connected do you/loved one feel?
Please Select
Very connected
Somewhat connected
Often feel isolated
Very isolated
Are there any safety concerns at home?
Please Select
No concerns
Minor concerns (falls, stairs, etc.)
Yes, I’m worried about their safety
What are you looking for today?
Please Select
Immediate help
Planning for the near future
Just exploring options
Primary Tag
Submit
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