I Don't See My City 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?YesNoDid you or your spouse serve at least 90 days of active duty with at least 1 day during wartime?YesNoDo you or your spouse receive an Honorable Discharge?YesNoIn 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.?YesNoNOT 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.)?YesNoZip 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
