East Hampton, New York We provide home care services in East Hampton & other surrounding communities. General Questions? Ask Here Employment Questions? Ask Here Use the Form Below or Call 631-685-5001 for Immediate Information 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 Unique Needs/Acupuncture, etc. 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?* Yes No I don't know 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*How Did You Hear About Us?* CAPTCHA
