Lifeline Home Care, Inc. In-home Caregivers - Elderly & Disabled

For People Looking for Services

Salutations:
Fisrt Name:
Last Name:
Zip Code:
Primary Phone:
Secondary Phone:
Email:

What funding source will be the primary payer for services?
(Please Select One)

Private Pay
Medicare
Combination (Private Pay & Medicare)
Medicaid / Public Assistance
Long Term Care Insurance

How much have you budgeted for these“out-of- pocket”expenses?
(Please Select One)

Less than $250 per week
$250 to $500 per week
$500 To $1,000 per week
$1,000 to $1,500 per week
Over $1,500 per week

For whom are you interested in setting information regarding eldercare services? (Please Select One)

Self
Spouse
Parent/Child
Grandparent
In-Law
Sibling
Other Relative
Friend

Please provide the following information about the recipient:
Gender:
Age:

When would you like services to begin?
(Please Select One)

Immediately
Within 2 weeks
Within 4 weeks
Within 6 weeks

Which of the following best describes the care recipient’s current living arrangement? (Please Select One)

At home and living independently
At home with some services in place
Assisted living facility
Skilled nursing Facility/nursing Home
Hospital or rehabilitation facility

Toll Free 800 999 8796 We Guarantee to:
Fairfax County TEL: 703-543-7511 703-825-7640 FAX: 703-543-7512	Fauquier County TEL: 540-349-8513 FAX: 540-349-8414
Return all phone calls within 1 hour.
Provide a resource with 24 hours of being engaged.
Seven Days a Week
Short Term/Long Term & Hourly
RN’s, LPN’s, CNA’s, HHA’s
Homemakers and Companions
Live-In/Live-out & Live-In Plus
Serving the DC Metro Area