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(732) 205-1635
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Help Us Get To Know You Better
Who needs Care at Home?
*
-Select-
Myself
Spouse
Parent
Grandparent
Other Relative
Friend
Other
How Old is the Person Who Needs Care?
*
-Select-
45-54
55-64
65-74
75-84
85 or older
Male or Female?
*
-Select-
Male
Female
What is their current living situation?
*
-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
Nursing Home
Estimate How Much Care They Might Need
*
-Select-
A few hours per week
More than 20 hours per week
40 or more hours per week
Around-the-Clock Care
Live-In Care
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
How will care be paid for?
*
Private Funds
Long-Term Care Insurance
Medicaid
Other (VA Aid and Attendance, Reverse Mortage, etc
Many Senior In-Home Care services and products are not covered by insurance, Medicare, Medicaid or public assistance. Most individuals and families often need to pay "out-of-pocket" for some or all services requested. Are there other sources of financing available to you, such as Social Security benefits, VA benefits, or Private Funds?*
*
Yes
No
I do not know
Zip Code Where Care is Needed
*
Name of Person Submitting this Form
*
Phone Number of Person Submitting this Form
*
Your Email Address-WE will send you information via email
*
Key Home Care
267 Amboy Ave, Suite 18, Metuchen, NJ 08840
(732) 205-1635
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