Self Assessment
Who Needs Care?
Myself
Spouse
Parent
Grandparent
Other Relative
Friend
Other
Select One
How Old is the Person Who Needs Care?
Under 18
18 - 44
45 - 54
55 - 64
65 - 74
75 +
Select One
Male or Female?
Male
Female
What is the current living situation of the person needing care?
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
Nursing Home
What 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
Type option 3
Type option 4
Other
How Much Care is Needed
A few hours per week
40 or more hours per week
Around-the-Clock Care
Livin-In Care
Name of Person Submitting this Form
Name
First Name
Last Name
Email (optional)
Phone Number of Person Submitting this Form
-
Area Code
Phone Number
Best Time to Contact You
Morning
Afternoon
Evening
Other Comments or Messages?
Submit
Should be Empty: