CareWise Information Request Form

FREE Initial Consultation!

The information you provide will help us in our initial assessment of your needs and allow us to determine the urgency of your request. This is representative of the information we will need to gather in our interviewing process, but is not indicative of the entire depth of our assessment.

Tell Us About Your Needs
*	What type of services do you feel are needed?
	Companionship & Supervision Cooking Counseling and Emotional Support Errands Housekeeping Incontinence Care Medication Management Nursing Care Overnight Care Personal Care (Bathing, Dressing, etc.) Psychiatric Care Shopping Social or Educational Activities Transportation Other:
*	I am making this request because:
	-- Select One -- This is a new need and I welcome advice I do not live in the area and need help I want to replace my current service provider I want to research options available
*	When would you like care to begin?
	-- Select One -- Immediate Care Needed Within Two Weeks Within Four Weeks Within Six Weeks Within 8 Weeks Flexible
*	Budget per week for support services:
	-- Select One -- $200 - $300 $300 - $400 $400 - $500 $500 - $750 $750 - $1,000 $1,000 - $1,500 $1,500 And Above Unsure
	What is most important to you?
	Atmosphere/Comfort Level Equipment & Amenities Financial Considerations Safety Provisions Services & Activities Staff & Residents Other:
*	Who is this care for?
	-- Select One -- Friend Grandparent Parent Spouse
*	Have you and your family discussed and come to some resolution on how you would fund the care for your elderly parent or relative?
	-- Select One -- Have Not Discussed Life Insurance Long-Term Care Insurance Medicaid Medicare Out of Pocket Reverse Mortgage
*	Who is the current primary caregiver of the person needing care?
	-- Select One -- No One Spouse Child Sibling Friend Nursing Home In-Home Care Provider Other (See Details Field)
*	How long do you need this care?
	1 Week  1 Month  Long-Term Unsure
*	Have you pursued other elder care options before now?
	No Yes (please include the specific type(s) in the Details section below)
*	Age of person needing care:
*	Gender:
	Male  Female
*	Do you feel that the person needing care will be willing to accept care by a non-family member?
	Yes No Not Sure
*	What existing medical conditions does this person have?
	None Alzheimer's/Dementia Arthritis Cancer Depression Diabetes Eye Disease Heart Disease HIV/AIDS High Blood Pressure High Cholesterol Hypertension Incontinence Osteoporosis Parkinson's Respiratory Disease Stroke Surgery Other:
*	Which type of placement most interests you?
	-- Select One -- Adult Day Care Center Assisted Living Facility In-Home (Full Time) In-Home (Part Time) Skilled Nursing Facility Other (See Details Field)
*	Details:

Your Contact Information
We will only use your email address to send you information about your request. Your email address will NOT be disclosed to anyone. This request requires you to provide your name and phone number, where we will contact you after reviewing the information you have provided.  Your information will NOT be disclosed to anyone outside of CareWise.
*	I would like to receive responses at this email address:

*	First Name:    Last Name:

*	Phone Number: ()     Best Time to Call (Daytime Preferred): -- Select One -- Morning Afternoon Evening Weekend No Preference

	You will receive a response as soon as we are able to process your request.  All information shared will be held in confidence and NOT disclosed to anyone without your prior and express permission for the sharing of information.
Not interested in submitting a request?   Please, tell us why (this will assist us in better serving our inquiries).

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