I Don't See My City

• When you fill out this form you can expect information and communication with a caring staff member from our office.

• Name of Person Submitting this Form*
  First Last
• Phone
• Your Email Address- We will send you information via email.*
• Would you like a FREE assessment?
  • Yes
  • No
• Are you looking for employment?
  • Yes
  • No
• Message
• Who Needs Care at Home?*
  Select OneMyselfSpouseParentGrandparentOther RelativeFriendOther
• How Old is the Person Who Needs Care?*
  Select One45-5455-6465-7475-8485 or older
• Male or Female?*
  Select OneMaleFemale
• What 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 Home
• Estimate 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 Care
• What Type of Care is Needed? (Check all that apply)*
  • Light Meal Preparation
  • Light Laundry
  • Light Housekeeping
  • Companionship
  • Transportation to Appointments
  • Grocery Shopping
  • Errands
  • Bathing
  • Toileting
  • Medication Reminders
  • Respite Care
  • Hospice
• How will care be paid for?*
  • Private Funds
  • Long-Term Care Insurance
  • Medicaid
  • Other - (VA Aid and Attendance, Reverse Mortgage, etc)
• Many Senior In-Home Care services and products are not covered by insurance, Medicare, Medicaid or public assistance. Most individuals and families often need to pay "out-of-pocket" for some or all services requested. Are there other sources of financing available to you, such as Social Security benefits, VA benefits, or Private Funds?*
  • Yes
  • No
  • I don't know
• Do you have experience?*
  • RN
  • CNA License
  • HHA Certification
  • LVN/LPN Certification
  • First Aid Certification
  • CPR Certification
  • None
• Do you have a driver's license?*
  • Yes
  • No
• Do you have a your own transportation?
  • Yes
  • No
• Do you have Car Insurance?
  • Yes
  • No
• What days are you available to work? (Check all that apply)
  • Sunday
  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday
  • Saturday
• When are you available to work? (Check all that apply)
  • Mornings (6am - 12pm)
  • Afternoons (12pm - 4pm)
  • Evenings (4pm - 10pm)
  • Overnights (10pm - 6am)
  • Live In (24 hours)
• How did you hear about us?*
  Select OneAdvertisementJob FairCraigslistFriend/ Family ReferralSearch EngineOther
• Have you ever been convicted of a felony?*
  • Yes
  • No
• Phone Number of Person Submitting this Form*
• Zip Code Where Care is Needed*
• CAPTCHA