Care at Home Specialists provides senior home care services in Chicago

Call Us - (847) 850-7540

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Contact Information

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

Ext.
Ext.

Please select any services that you believe are required for the Care Recipient:

(Please select all that apply)

 Bill Payment / Household Financial Management  Live In Home Care
 Companion Services  Meal Preparation
 Geriatric Assessment / Evaluation  Transition Services (e.g., home sale, relocation, downsizing or asset liquidation)
 Home Healthcare (Medical)  Transportation Medical (Non-Emergency)
 Home Renovation / Maintenance  Visiting / Private Duty Nursing
 Homecare (Non-Medical)  Rehabilitation Services (e.g. Physical Therapy)
 Homemaker/ House Cleaning  Handy Man Services / Odd Jobs / Misc. Household Repairs
 Personal Care (e.g. Bathing, Toileting or Grooming)  Installation of Ramps / Rails /Grab Bars etc.

What funding source will be the primary payer for the services or products?

(Please select one)

 Private pay  Long Term Care Insurance  Combination (Private Pay & Medicare)

Consumer Needs Survey

For whom are you interested in getting information regarding eldercare products and services?

(Please select one)

 Self  InLaw
 Spouse  Sibling
 Parent  Other Relative
 Child  Friend
 Grandparent

Gender: Age

When would you like services to begin or products to be delivered?

(Please select one)

 Immediately  Within 4 Weeks
 Within 2 Weeks  Within 8 Weeks

Please indicate the number of hours of support services that you estimate the care recipient requires.

(Please select one)

 More than 100 hours per week  10 to 20 hours per week
 40 to 100 hours per week  0 to 10 hours per week
 20 to 40 hours per week

What, if any, existing medical conditions does the care recipient have?

(select all that apply)

 ALS  Incontinence
 Alzheimer's / Dementia  Joint Replacement
 Ambulatory Problems  Macular Degeneration / Low Vision
 Arthritis Other  Eye Disorders & Diseases
 Cancer  Osteoporosis
 Cancer  Parkinson's
 Depression  Respiratory Disease
 Diabetes  Stroke
 Hearing Impaired  Surgical Recovery
 Heart Disease  Disease or Condition Not Listed
 High Cholesterol  None/Unsure
 Hypertension / High Blood Pressure
Map of location Request a quote Contact info

Call Care at Home Specialist today at (847) 850-7540 or e-mail us at: info@careathomespecialist.com to discuss your in home care needs and questions.
Our case managers will contact you to discuss an appropriate care plan.

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