Fill out our questionnaire to get immediate options for your loved one. Phone Who are you concerned about? Mom Dad Myself Other What's your name? Email Address * Phone Number * Address (We will mail you our information): Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 1. What prompted you to contact us? Pre-planning Writings on the wall Full blown crisis 2. What sort of information are you most looking for (check all that apply) Subsidized housing or apartment Independent living Care facility (Assisted living, nursing home, dementia community) Respite care (Temporary help) Home care Financial options Senior resources 3. Where are they right now? Home Hospital Rehab Senior care facility Living with family/friends Other 4. How old are they? 62 and under 65+ 75+ 85+ 5. What care needs do they have? Walking Standing Dressing Using the bathroom Medication management Meal preparation Transportation Cueing and redirection for memory loss Safety needs (Wandering, using the stove, fraud target) 6. What health conditions do they have? Dementia/Alzheimer's Parkinson's Congestive heart failure or COPD Diabetes Depression/Anxiety Aggression/Other behaviors Wandering/Exit seeking 7. What area are you looking for services? NW GR SW GR SE GR NE GR Lakeshore Other If you selected ' Other', please describe 8. What financial benefits do they have now? Medicaid Medicare Disability Medicaid waiver Veteran Spouse of a veteran Long-term care insurance Reverse mortgage 9. What is their gross income (per person if a couple) Less than $1,000 per month $1,000 to $1,500 per month $1,500 to $2,200 per month $2,200 to $3,500 per month $3,500+ 10. Do they have savings? No, they live on income alone If yes, Less than $10,000 $10,000 to $50,000 $50,000 to $100,000 $100,000 + Anything else you'd like us to know? How did you hear about Crossroads Eldercare Options? * recaptcha
