Who Needs Care? *
—Please choose an option—ParentDaughterSonSpouseOther RelativeNeighbor/Friend

What Age is the Person Who Needs Care? *
—Please choose an option—45-5455-6465-7475-8485-Older

Male or Female? *
—Please choose an option—MaleFemale

What is their current living situation? *
—Please choose an option—Living 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 *
—Please choose an option—A 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) *
—Please choose an option—Bathing/Showering and grooming assistanceToileting and incontinence careMedication remindersLight meal preparationErrands/Shopping/PharmacyLight housekeepingight laundryCompanionshipEscort on appointments (doctor's office, hair salon, etc)Safety SupervisionRespite CareAlzheimer's and dementia careHospiceAssisted Living Placement (only for Legacy Home Care)Other

First Name *

Last Name *

Email *

Phone*

Zipcode *

READ/AGREE WITH THIS STATEMENT: I understand that I will be receiving a call and emails from a staff member of Home Care Resources. The purpose of the call is to understand more about my job opportunities. There is no obligation to purchase any services. You agree to receive automated messages. This agreement is not a condition of purchase. Receive up to 8 messages per month. Reply STOP to opt-out or HELP for help. Message & data rates apply. Terms and privacy policy found here.

I Agree/Authorize/Consent