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Preferred Date *

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Care Selector

- Step 1 of 6

Where are you located? *

Fairbanks - In Town
Fairbanks - Out of Town
North Pole
Other Area

How soon do you need placement? *

Now
1-2 Weeks
1-2 Months
3 Months +

Which of the following care options do you need? *

Respite Care
Companionship Care
Daily Living Needs
Diabetic Care
Dementia
Alzheimer’s
Transportation
Hospice
Other (enter detail below)

Other Information:

To help determine your assessment process please indicate if you are approved for any payment assistance: *

Medicaid
VA Benefits
Long-Term Care Insurance
Other (please detail below)

Other Information:

Thank you for taking the time to complete the Caregiver Matching Survey. If you would like our local home care expert to personally review this information and answer any other questions, please fill out the following contact information.

Name *

Email *

Phone *

How would you like to be contacted? *

Email
Phone
No Preference

Additional Info

Name

Caregiver Matching Service

- Step 1 of 8

Where are you located? *

Fairbanks - In Town
Fairbanks - Out of Town
North Pole
Other Area

How soon do you need placement? *

Now
1-2 Weeks
1-2 Months
3 Months +

How many days per week do you anticipate needing a caregiver? *

1-2 Days
3-4 Days
5-6 Days
All Week
I'm not sure right now

How many hours per day will you need a caregiver? *

2-5 Hours
5-8 Hours
8-12 Hours
12-15 Hours
24-Hour Care
I'm not sure right now

Which of the following care options do you need? *

Respite Care
Companionship Care
Daily Living Needs
Diabetic Care
Dementia
Alzheimer’s
Transportation
Hospice
Other (please detail below)

Other Information:

To help determine your assessment process please indicate if you are approved for any payment assistance: *

Medicaid
VA Benefits
Long-Term Care Insurance
Other (please detail below)

Other Information:

Thank you for taking the time to complete the Caregiver Matching Survey. If you would like our local home care expert to personally review this information and answer any other questions, please fill out the following contact information.

Name *

Email *

Phone *

How would you like to be contacted? *

Email
Phone
No Preference

Additional Info

Website

Pricing & Availability Inquiry

- Step 1 of 6

1) Which home are you most interested in? *

Aurora Home
University West Home

2) How soon do you need placement? *

Now
1-2 Weeks
1-2 Months
3 Months +

3) Which of the follow care options do you need? *

Bathing & Grooming
Meal Preparation
Incontinence
Mobility
Diabetic Care
Dementia
Alzheimer’s
Doctors Appointment Transportation
Hospice
Other (please detail below)

Other Information:

4) To help provide you with an accurate monthly cost please indicate if you are approved for any payment assistance: *

General Relief
Medicaid
VA Benefits
Long Term Care Insurance
Other (please detail below)

Other Information:

Thank you for taking the time to complete the Pricing and Availability inquiry. If you would like our Administrator to personally review this information, please fill out the contact info below.

Name *

Email *

Phone *

How would you like to be contacted? *

Email
Phone
No Preference

Additional Info

Comment