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Personal Information
Full Name
Email
Phone Number
General Assessment
What is the age of the individual needing care?
What is your current living arrangement?
Living at home
Living with family
Assisted living facility
Other
Please specify
Health and Care Needs
Does the individual have any specific medical conditions or disabilities we should be aware of?
Yes
No
Please specify
Does the individual require assistance with daily living activities?
Yes
No
Please specify the type of assistance needed:
Bathing and showering
Personal hygiene and grooming (including brushing teeth, combing hair)
Dressing
Toileting and maintaining continence
Transferring (moving from bed to chair, or chair to standing)
Walking or mobility
Eating and feeding oneself
Expectations
What are the key factors you are looking for in a personal care home?
Cost
Location
Services Offered
Staff Qualifications
Atmosphere
Other
Please specify
Expected Care Duration
How long do you anticipate needing the services?
Short-term (less than 6 months)
Medium-term (6 months to 2 years)
Long-term (more than 2 years)
Budget Consideration
What is your monthly budget for personal care services?
Under $3,500
$3,501 - $5,000
$5,001 - $6,500
$6,501 - $8,000
Over $8,000
Income Source
What are your primary sources of income?
Social Security
Pension
Savings and investments
Family support
Long-Term Care Insurance
VA
Other
Please specify
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