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1
Who is the care for?
Parent
Self
Spouse
Grandparent
Other
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2
How old is the person receiving care?
55-65
65-75
75+
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3
What type of care are you or your loved one looking for?
Medical
Physical/Occupational Therapy
Recreation and Socialization
Home Health Aide
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4
When would you like care to begin?
Immediately
In 1 month
In 3 months
6 months +
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5
Tell us more about what type of insurance you or your loved one has.
Medicaid
Medicare
Both Medicare and Medicaid
I/They would like to apply for Medicaid.
Private Pay
I don't know
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6
A care representative is ready to schedule your tour! Please share your name with us.
First Name
Last Name
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7
Phone Number
Area Code
Phone Number
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8
If you would like to get further updates and information, please share your email.
example@example.com
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