Boiling Springs Use Form Below for Info & Pricing Or Call (864) 527-0455 Who Needs Care?*Select OneMyselfSpouseChildParentGrandparentOther RelativeFriendOtherHow Old is the Person Who Needs Care?*Select One0-4445-5455-6465-7475-8485 or olderMale or Female?*Select OneMaleFemaleWhat is their current living situation?*Select OneLiving Alone at HomeLiving at Home with FamilyIn the Hospital Needs a SitterIn the Hospital Discharging to HomeAssisted LivingIndependent Senior LivingNursing HomeEstimate How Much Care They Might Need*Select OneA few hours per weekMore than 20 hours per week40 or more hours per weekAround-the-Clock CareLive-In CareWhat Type of Care is Needed? (Check all that apply)* Companionship Light Meal Preparation Light Laundry Light Housekeeping Companionship Transportation to Appointments Grocery Shopping Errands Bathing Toileting Medication Reminders Respite Care Other How will care be paid for?* Private Funds Long-Term Care Insurance Medicaid VA Aid and Attendance Other (Voucher, Worker’s Comp, etc.) Are you a Veteran? Yes No Did you or your spouse serve at least 90 days of active duty with at least 1 day during wartime? Yes No Do you or your spouse receive an Honorable Discharge? Yes No In which war did you or your spouse serve? WWII (Dec 7, 1941 - Dec 31, 1946) Korean War (Jun 7, 1950 - Jan 31, 1955) Vietnam Era (Aug 5, 1964 - May 7, 1975) (Feb 28, 1961 - Aug 5, 1964 ”in-country” only) Gulf War (Aug 2,1990 - TBD by Presidential Proclamation) I don’t know Do you require assistance from a caregiver to help with bathing, dressing, meals, walking, medication management, transportation, etc.? Yes No NOT including your home or personal property (vehicle, boat, etc), are your assets valued at less than $123,000 (Assets are cash, income, stocks, mutual funds, etc.)? Yes No Zip Code Where Care is Needed* Name of Person Submitting this Form* First Last Your Email Address- We will send you information via email.* Phone Number of Person Submitting this Form*CAPTCHA
