Get Started with Us.Get Your Free Care Consultation. Use This Form to Receive Immediate Info When you fill out this form you can expect information, pricing and communication with a caring staff member from our office. Who Needs Care at Home?*Select OneMyselfSpouseParentGrandparentOther RelativeFriendOtherHow Old is the Person Who Needs Care?*Select One45-5455-6465-7475-8485 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)* Bathing/Showering and grooming assistance Toileting and incontinence care Medication reminders Light meal preparation Errands/Shopping/Pharmacy Light housekeeping Light laundry Companionship Escort on appointments (doctor’s office, hair salon, etc) Safety Supervision Hospice Care Respite Care Alzheimer’s and dementia care Other How will care be paid for?* Private Funds Long-Term Care Insurance Other 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 agree to the privacy policy. (Bottom of Page) I understand that by entering my information, I will be receiving a call and emails from a staff member of Central Star Home Health.
