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June 20, 2013

At ParentCareUSA we offer customized services tailored to your situation. We have designed a brief questionnaire that will provide us with introductory information about your circumstances, allowing us to better assess your needs. Please be assured that all information provided is strictly confidential and will be handled with complete discretion, (see privacy statement).

We will contact you shortly to set up a free initial consultation.
     
   1. Client Information
email
name
address
city

state
zip code
home phone
work phone
fax
cell phone
best time to call
call me at
   2. Person requiring assistance
name
address
city
state
zip code
phone
age
   3. Your relationship to the person requiring assistance:
relationship
   4. What medical conditions does the person have?
  Please check all that apply
Alzheimer's Disease / Dementia
Arthritis
Cancer
Chronic Obstructive Pulmonary Disease
Depression
Diabetes
Heart Disease
Osteoporosis
Parkinson's Disease
Stroke
Other: 
   5. Where does this person currently live?
Own
Rent
Retirement Community
Assisted Living Facility
Nursing Home / Skilled Nursing Facility
Other: 
   6. With whom does this person live?
Lives Alone
Lives with Relatives
Lives with Others
None of the Above
   7. In your opinion, what are this person's greatest care needs?
  Please check all that apply
Personal Safety
Nursing Care
Assistance with Activities of Daily Living
Adult Day Care
Medical Alert Systems
Homemaker Services
Home Maintenance (lawncare, snow removal, repairs, etc.)
Other: 
   8. Which pay sources does this person have?
  Please check all that apply
Medicare
  Part A    Part B  
Medicare Supplemental Insurance (i.e. AARP, Medi-Gap, etc.)
Medicaid
HMO
Private Insurance
Long Term Care Insurance
Private Funds
   9. What is the estimated total value of all assets owned by
    the person, NOT including the family home?
$0 - $2,000
$2,000 - $25,000
$25,000 - $50,000
over $50,000
   10. Which of our services do you feel will be most helpful
      at this time?
  Please check all that apply
Comprehensive Caregiving Assessment
Care Management Services
Eldercare Consultation and Advice
Facility Assessment / Placement
Medicaid Asset Protection & Planning Strategies
Medicaid Application
Elderlaw Services
Other: 
   11. Please use this space to tell us more about how we can help?
 
     
         
 
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