Sound Options, Inc.

"It's OK to reach out...I am part of the 'sandwich generation'..."
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	Care Management Services What is a Care Manager? Care Management Lifestories

Eldercare Needs Survey

Think you may need our services but don’t know where to begin?
In order to assist you in obtaining the best care solutions to meet your current needs, please provide the following information for the person completing the survey and requesting information, and one of our Care Team will respond to you shortly.

Salutation:
First Name:
Last Name:
Email:
Zip Code:
Primary Phone:
Secondary Phone:

Which service area below, best describes your primary need?

	Professional Care Manager (e.g. family consultation, in home assessment, strategic care plan and implementation, advocacy, liaison to physicians and other professionals, ongoing monitoring)
	Home Care Services (e.g. non-medical homecare, home healthcare, companionship & safety, transportation, personal care, medication reminders, housekeeping & errands, grocery shopping & meal preparation, supplemental care in a retirement or assisted living community)
	Eldercare Coaching (nation-wide telephone consulting service with professional experts, providing immediate customized resources and referrals tailored to your needs)

Please provide the desired location for the services to be provided to the care recipient:

City:

State:

Zip:

The intended care recipient is my:

	Parent			Grandparent
	Sibling			Self
	Other

Please select your preference for where care is to be provided:
(check all that apply)

	In-Home
	Independent Living / Senior Community
	Assisted Living

Please select any services you believe may be required for the
Care Recipient: (check all that apply)

	Geriatric Assessment / Evaluation			Homecare (non-medical)
	Personal Care (e.g. bathing, toileting)			Companion (Safety or grooming)
	Live In Home Care			Meal Preparation
	Homemaker / Household Services			Transportation Non-medical (e.g. Errands, Shopping, Doctor appt.)
	Occupational Therapy			Customized Care Plans

Do you want or need any of the following services?

	Geriatric Care Manager			Real Estate Agent
	Family Mediation / Conflict Resolution			Estate Planning
	Financial Planning			Long Term Care Planning
	Reverse Mortgage Lender			Eldercare Placement Services
	Legal/Elder Law Services			Family Consulting

What will be the primary funding source for payment of services?

	Private Pay
	Combination (Private Pay & Medicare)
	Long Term Care Insurance

How did you find our web site?

I understand the information provided by me is intended for the sole use of Sound Options, for the purpose of evaluating my potential needs and making subsequent recommendations for professional Eldercare services, and will not be shared with or sold to any third party. I am aware I will receive next month’s Sound Options e-news, and may opt out at any time.

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