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Get Started with Companion Services of America. Fill out the form below.
Use This Form to Receive Immediate Info
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?
How Old is the Person Who Needs Care?
85 or older
Male or Female?
What is their current living situation?
Living Alone at Home
Living at Home with Family
In the Hospital Needs a Sitter
In the Hospital Discharging to Home
Independent Senior Living
Estimate How Much Care They Might Need
A few hours per week
More than 20 hours per week
40 or more hours per week
What Type of Care is Needed? (Check all that apply)
Light Meal Preparation
Transportation to Appointments
How will care be paid for?
Long-Term Care Insurance
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?
I don't know
Zip Code Where Care is Needed
Name of Person Submitting this Form
Your Email Address- We will send you information via email.
Phone Number of Person Submitting this Form
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