Home Care Provider Form1-800-HOMECARE

Please complete the form below.

Please provide the location for the service

City

State / Province / Region

Postal / Zip Code

Which choice below best describes your primary need:

Eldercare Residence
Home Services and/or Adult Day Care Services
Both Eldercare Residence and In-Home Options

Where will your care be provided?

In-Home
Adult Day Care Facility
Independent Living / Senior Community
Group Home / Residential Care Home
Assisted Living Facility
Continuing Care Retirement Community
Skilled Nursing Facility / Nursing Home

What financial support will be the primary payer for the services?

Private pay
Medicaid / Public Assistance
Medicare
Long Term Care Insurance
Combination (Private Pay & Medicare)
Other

What will your budget be for these “out-of-pocket” expenses?

Less than $250 per week
$250 to $500 per week
$500 to $1,000 per week
$1,000 to $1,500 per week
Over $1,500 per week

For whom are you interested in getting information regarding eldercare products and services?

Self
Spouse
Parent
Child
Grandparent
InLaw
Sibling
Other Relative
Friend

Please provide the following information about the care recipient.

Gender

Male Female

Age

When would you like services to begin or products to be delivered?
(Please select one)

Immediately

Within 2 Weeks

Within 4 Weeks

Within 8 Weeks

Please indicate the number of hours of support services that you estimate the care recipient requires.
(Please select one)

More than 100 hours per week

40 to 100 hours per week

20 to 40 hours per week

10 to 20 hours per week

0 to 10 hours per week

What, if any, existing medical conditions does the care recipient have?
(select all that apply)

ALS

Alzheimer’s / Dementia

Ambulatory Problems

Arthritis

Cancer

Colostomy

Depression

Diabetes

Hearing Impaired

Heart Disease

High Cholesterol

Hypertension / High Blood Pressure

Incontinence

Joint Replacement

Macular Degeneration / Low Vision

Other Eye Disorders & Diseases

Osteoporosis

Parkinson’s

Respiratory Disease

Stroke

Surgical Recovery

Disease or Condition Not Listed

Emphysema /COPD

None/Unsure

Which of the following best describes the care recipient’s current living arrangement?
(Please select one)

At home and living independently

At home with some services in place

Assisted living facility

Skilled nursing facility / nursing home

Hospital or rehabilitation facility

How would you describe the care recipient’s feelings about receiving assistance?

Very Receptive

Somewhat Receptive

Resistant to Help

Unaware

Please include any additional information that you think may prove helpful in matching your needs with our network of providers.

Understanding Home Care

Home Care Provider Form

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Canada