Get Care - Home Care Website Design Template

Who needs care or help at home?

A loved one Myself A client Other

What is the care recipient’s first name?

What is the care recipient’s last name?

When do you need to start care?

Immediately In the Coming Weeks Planning for the Future Not Sure

Do you know how much care you’ll need?

A few hours a day Most of the day Around the clock support Not sure

Are you planning for long-term care?

No, just a few weeks Yes, we need a long-term solution Not sure

Do you need any additional services?

Care Management and Oversight Because Family is Far Away or Overwhelmed Help Navigating Complex Family Dynamics Health Advocacy With Physicians, Hospital, or Insurance Agency Coordination of Health, Legal, or Financial Planning House Management, Help Around the House, or Coordinating Repairs Assistance With Finding and/or Moving to an Ideal Home or Community None/Other

Have you had home care from a professional caregiver before?

Yes No

Is the care recipient open to receiving care or resistant?

Open Resistant Not Sure

How are you planning to pay for care?

Private pay/out-of pocket Long-term care insurance Medicare/Medicaid/Medicare Waiver Not sure

What goals are you hoping to accomplish by setting up home care?

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