Get Started with Us. Get Your Free Care Consultation. Use This Form to Receive Information When you fill out this form you can expect immediate information, pricing and communication with a caring staff member from our office. Who Needs Care at Home?*Select OneChildMyselfSpouseParentGrandparentOther RelativeFriendOtherHow Old is the Person Who Needs Care?*Select OneUnder 18Adult 18-4545-5455-6465-7475-8485 or olderMale or Female?*Select OneMaleFemaleWhat is their current living situation?*Select OneLiving Alone at HomeLiving at Home with FamilyIn the Hospital Needs a SitterIn the Hospital Discharging to HomeAssisted LivingIndependent Senior LivingNursing HomeEstimate How Much Care They Might Need*Select OneA few hours per weekMore than 20 hours per week40 or more hours per weekAround-the-Clock CareLive-In CareWhat Type of Care is Needed? (Check all that apply)* Light Meal Preparation Light Laundry Light Housekeeping Companionship Transportation to Appointments Grocery Shopping Errands Bathing Toileting Medication Reminders Respite Care Hospice How will care be paid for?* Private Funds Long-Term Care Insurance Medicaid Other - (VA Aid and Attendance, Reverse Mortgage, etc) Zip Code Where Care is Needed*Name of Person Submitting this Form* First Last Your Email Address- We will send you information via email.* Phone Number of Person Submitting this Form*Consent* I understand that by filling out this form, a staff member from Extended Family Care will reach out to me by email and phone.
