First Name

Last Name

Email *

Postal code

Phone *

I consent to receiving phone calls and SMS communications from Christian Companion Senior Care regarding at home health care services

Hours of Care Needed Per Week *

Please Select

0-12
13-24
25-40
40+
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Days of Care Required (Select All That Apply) *

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Time Care Is Needed *

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Day
Night
Both
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Long Term Care Insurance? *

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Yes
No
Unsure
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Level(s) of Care / Services Needed *

Companionship

Daily Living Assistance

Skilled Nursing

24 Hour

Alzheimer's / Dementia

Post Hospital

Parkinson's

Inside Community Care

Other

How Soon Would You Like To Start? *

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Immediately
Within 1 Month
1-3 Months
4+ Months Away
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Relationship To Individual Needing Care *

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Spouse
Parent
Other Family Member
Friend
Unrelated Caregiver
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