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Who is in need for senior care?
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Select Who
Husband/Wife
Parents
Myself
I want to refer someone
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What is the age of your loved one?
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50+
60+
70+
80+
90+
100+
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When do you need the care for your loved one
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Select When
Immediately
Within 7 days
Within 30 days
No rush
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Where is your loved one currently living?
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Home (lives alone)
Home (lives with someone)
Assisted living
Nursing home/Rehab Facility
Hospital
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How are they getting around?
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Select How
Independent
Walker
Wheelchair
Cane
Immobile
Bedridden
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Do they need assistance to any of the following?
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Medication
Toileting
Bathing
Diabetic Care
Special Diet
Housekeeping
Social Activities
None
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Have they experienced any of these behaviors?
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Wandering
Withdrawal
Sundowning
Judgement loss
Inappropriateness
24 Hour Care
Exit Seeking
None
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Is your loved one currently experiencing memory loss?
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Select
Yes
No
Not Sure
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How many hours of care needed per week?
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Select Hour/s
Less than 10
11 to 20
21 to 40
40+
Not Sure
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What’s the main reason you’re considering home care?
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Select Reason/s
Discharge from hospital/Rehab
Alzheimers or Dementia Diagnosis
Needed 24/7 Care
No Family Caregiver
Change in Lifestyle
Other
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First Name
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Last Name
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Email
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