I Don't See My City We Provide Care in the following cities and surrounding areas: Northbrook Highland Park Deerfield Glenview Buffalo Grove Evanston Des Plaines Skokie Lake Forest Wilmette If you aren't sure if we service you area, please contact us today. Use This Form to Receive Immediate Info 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)* 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) Many Senior In-Home Care services and products are not covered by insurance, Medicare, Medicaid or public assistance. Most individuals and families often need to pay "out-of-pocket" for some or all services requested. Are there other sources of financing available to you, such as Social Security benefits, VA benefits, or Private Funds?*YesNoI don't knowZip Code Where Care is Needed*Name of Person Submitting this Form* First Last Your Email Address- We will send you information via email.* CAPTCHAPhone Number of Person Submitting this Form*