Let’s Get Started * Let’s Get Started * Let’s Get Started * Name * Email * Phone * (###) ### #### Do you need care in Arizona? * Yes Who needs care at home? * Myself Parent Grandparent Other Relative Friend Other How old is the person who needs care? * 44 or younger 45-54 55-64 65-74 75-84 85 or older What is their gender? * Male Female What is their current living situation? * Living at home alone Living at home with family In the hospital, needs a sitter In the hospital, discharging to home Assisted living Independent senior living Please estimate how much care is needed. * A few hours per week More than 20 hours per week 40 or more hours per week Around-the-clock care Live-In Care How will care be paid for? Private funds Long-Term Care Insurance Medicaid Other (VA Aid & Attendance, Reverse Mortgage, Etc.) What type of care is needed? * Please select all that apply Personal Care Assistance Companionship Meal Preparation Laundry Housekeeping Medication Management Transportation Support Specialized Care Zip Code * Additional Comments Thank you!
