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I am a Georgia Resident (person in need of services)
Who is in need of Care at Home?
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How Old Is The Person Who Needs Care?
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Male or Female?
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What is their current living situation?
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Estimate How Much Care They Might Need
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What type of Care is Needed? (Check all that apply)
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Light Map 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?
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ZipCode Where Care is Needed?
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Your First Name (Contact Person)
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Your Last name (Contact Person)
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Your Email Address - Where you would like information sent
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Your Phone Number (Contact Person)
*
Additional Comments or Information
Submit
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