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CHOICE Advisory Services

CHOICE Guide

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Arrange for In-Home Care with A Helping Hand

* required fields
Care with A Helping Hand
CHOICE considers your information private and confidential
* Your name:
Relationship to the person needing care:
Your phone number:
Alternate phone:
* Your email address:
Your mailing address:
 
*Do you hold medical durable power of attorney for the person needing care?:
*Does the person needing care give permission to discuss care needs with care providers?:
When do you need care services to start?:
Please complete as much information below as possible:
Is care needed for one or two people?
Where does this person live?         City:
Zip Code:
Care needs (check all that apply)
Companionship Meal preparation
Housekeeping Errand running
Transportation Memory / confusion
Help dressing Bathing/grooming
Toileting Incontinence Management
Medications Transfer assistance / mobility / help walking around
Is this person accepting of care? Yes No Not certain
How do you intend to pay for care? (check all that apply)
Private pay Insurance
Medicare (insurance) Medicaid (out of money)
Not certain  
Additional comments: