Request Care - Innovative Living Home Care

Contact Information
Salutation
First Name*
Last Name*
Email*
Zip Code*
Primary Phone
Secondary Phone
Which one of the following describes your primary need: (*Select one)
- Home Services and/or Products that will allow you or the person you are concerned about to continue to live safely at home (e.g. non-medical homecare, home healthcare, companionship, adult daycare, transportation, household support services)
- In-Home Care (Provide me with options for both senior housing and in-home services)
- Medical Equipment and/or Eldercare Products (e.g. home medical products, durable medical equipment, ambulatory aids, hearing aids, personal medical alarms)
- Advisory and/or Consultative Services (e.g. elder law/legal, financial/investment advice, estate planning, long term care planning, care management, family counseling, placement support)
Please select any services that you believe are required for the Care Recipient: (Please select all that apply)
- Adult Day Care / Respite Care
- Bill Payment / Household Financial Management
- Companion Services
- Concierge and Errand Services
- Financial Planning
- Geriatric Assessment / Evaluation
- Home Monitoring
- Home Renovation / Maintenance
- Homecare (Non-Medical)
- Homemaker / Household Services
- Personal Care (e.g. Bathing, Toileting or Grooming)
- Live In Home Care
- Meal Preparation
- Transportation Non-Medical (e.g. Errands, Shopping)
- Transportation Medical (Non-Emergency)
How much have you budgeted for these "out-of-pocket" expenses? (please select one)
- Less than $250 per week
- $250 to $500 per week
- $500 to $1,000 per week
- $1,000 to $1,500 per week
- Over $1,500 per week
Please share any additional comments with us: