Contact Home » Contact Contact us Recipient Details * Receiving Medicaid? (Not to be confused with Medicare)YesNoNo, but in process / planning to apply Currently living with?A SpouseAn Adult ChildBy Myself Currently receiving help from?SpouseAdult Child(ren) or Other Family MembersNo One Do you have a diagnosis of any of the following (select all that apply)? *DementiaParkinson’sStrokeHeart diseaseCOPDChronic painIncontinenceNone of the aboveOther Have you had any falls in the last six months?NoYes, One FallYes, More Than One Fall Seeking the following support services (select all that apply) *Medications administrationDressingShoweringToileting and hygieneAt night Looking for the following care setting (select all that apply) *Independent Senior LivingAssisted Living FacilityAdult Foster HomeMemory CareNursing HomeNot sure Do you have long-term care insurance?YesNo Which best describes your monthly income?Less than $1,000$1,000 - $2,000$2,000 - $3,000$3,000 - $4,000More Than $4,000 Do you own your home?YesNo Which one best describes your finances: combined all investment / saving, IRA, checking account, any assets that can be liquidated if you move from your home *---Less Than $50,000$50,000 - $100,000$100,000 - $200,000$200,000 - $300,000$300,000 - $400,000Over $400,000Money is not an Issue Additional Comments Submit Email [email protected]
