ElderCarelink Needs Survey :: Find Local Services at ElderCarelink.com

We can help identify the perfect solution to your care needs.

Overwhelmed by all the choices around home care, assisted living centers, medical equipment and the many other care options you face for your loved one each day? We understand and we can help.

ElderCarelink's specialty is helping people just like you wade through all the choices and paperwork. Sound too good to be true? It isn't.

Update your survey today and be contacted this week by someone who can offer you the advice and expertise you have been looking for.

About this survey

In order for ElderCarelink to assist you, we will ask for your input on several important questions. The responses that you give us are very important, as they are the basis upon which we are able to match you with providers who can assist you. Simply put, our ability to assist you is directly related to the quality of information we receive from you.

Finally, because your results will be provided via email and phone we can only help you if you provide us with a valid phone number and e-mail address. If you are not comfortable providing us with this information then we will be unable to assist you.

Customer Testimonials

Thank you so much. After submitting my request, I received several calls right away. I sincerely appreciate how fast you responded. I have now connected with the proper people to take care of my needs. Thank you.

-- C.R. in Texas

I just can't tell you what a tremendous blessing your business has been to me! I got a call from the absolutely PERFECT caregiver within one minute-literally-of clicking the 'Submit' button on your request form! You're flawlessly prompt, professional and personal service is a rare commodity indeed in today's marketplace. I couldn't be a more satisfied client!

-- P.A. in North Carolina

Contact Information
Please provide the following information for the person completing the needs survey and requesting results.

Salutation:
First Name:
Last Name:
Primary Phone:	- - Ext.
Secondary Phone:	- - Ext.
Email:	Zip Code:
Best time to call:

Needs Information (Select one)
From the list of choices below, which one best describes your primary need:

Eldercare Residence (e.g. assisted living, nursing home, independent living or senior community)

Home Services and/or Adult Day Care Services that will allow you or the person you are concerned about to continue to live safely at home (e.g. non-medical homecare, home healthcare, companionship, adult daycare, transportation, household support services)

Both Eldercare Residence and In-Home Options (Provide me with options for both senior housing and in-home services)

Medical Equipment and/or Eldercare Products (e.g. home medical products, durable medical equipment, ambulatory aids, hearing aids, personal medical alarms)

Advisory and/or Consultative Services (e.g. elder law/legal, financial/investment advice, estate planning, long term care planning, care management, family counseling, placement support)

Business / Employment interested in employment opportunities or a business relationship with ElderCarelink.

Please provide the location for the service(s) or product(s) to be provided:
	City:		State:		Zip:

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

In-Home	Adult Day Care Facility
Independent Living / Senior Community	Group Home / Residential Care Home
Assisted Living Facility	Continuing Care Retirement Community
Skilled Nursing Facility / Nursing Home

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

Do you need or want any of the following Consulting / Advisory Services?
(Please select all that apply)

Does the care recipient need price quotes and/or more information on any of following? (Please select all that apply)

What funding source will be the primary payer for the services or products?
(Please select one)

How much have you budgeted for these "out-of-pocket" expenses?
(Please select one)