Senior Care Rockford Illinois (IL)

Items marked with * are required.

I am interested in: (Please select one) *
Homecare
I want a job with Visiting Angels
I am interested in a franchise

Your Name:*

Phone:*

Is this a cell phone? Yes No

Email Address:

Your Contact Preference:
Email Phone Text No Preference

Address:

City:

State: *
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Zip Code:

When would you like services to begin? (Please select one)
Immediately Within 2 Weeks Within 4 Weeks Within 8 Weeks

Best to Contact During: *
Day Evening

How did you hear about us? *

Please select Aging Care Alzheimer's Association Alzheimer's Foundation Area Dept on Aging Bing Doctor/Nurse/Hospital Facebook Former Client Friend/Family/Word of Mouth Google Hospice/Home Health Agency My Insurance Newspaper Newspaper Article Online Advertisement Other Radio - Ave Maria Radio - Beacon Radio - Fox News Radio - NPR Radio - Other Radio - Pandora/Online Radio - Sacred Heart Radio Rehab/Nursing Home Social Worker TV - A&E TV - Antenna TV TV - Aspire TV - BET Her TV - Bravo TV - Cleo TV - CMT TV - Comedy.TV TV - Cooking Channel TV - Court TV TV - Cozi TV - Crime & Investigation TV - Decades TV - Discovery Family TV - Discovery Life TV - DIY TV - E! TV - Food Network TV - Fox & Friends TV - Fox Business TV - Fox News TV - FYI TV - Game Show Network TV - Great American Country TV - Hallmark TV - Hallmark Movies Mysteries TV - IFC TV - INSP TV - Justice Central TV - LAFF TV - Lifetime Movies TV - Lifetime Real Women TV - ME TV TV - Movies! TV - Online Streaming Service TV - Other TV - OWN TV - Oxygen TV - POP TV - Reelz TV - Rewind TV TV - The Weather Channel TV - TLC TV - TV Land TV - TV One TV - USA TV - WE TV TV - WGN Vehicle (Wrapped) Veteran's Association Yahoo Yellow Pages

How did you hear about us? *

Facebook Friend/Family/Word of Mouth Print Radio TV Streaming Other

ZIP Code where care is needed: *

Do you have an interest in receiving a Free In Home Care Consultation?
Yes No

Join the Visiting Angels Community

We'll send you periodic updates about resources designed to help your loved one live at home.

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Are you looking for additional ways to contact Visiting Angels?

Additional Home Care Needs

Please complete the optional additional information form below.

Please select any services that you believe are required for your loved one: (Please select all that apply)

Homecare

Hospice Services

Homemaker / Household Services

Medication Reminders

Live In Homecare

Home Healthcare (Medical)

Companion Services

Meal Preparation

Home / Safety Monitoring

Assistance with Ambulation or Mobility

Transportation Non-Medical (e.g. Errands, Shopping)

Personal Care
(e.g. Bathing, Dressing, Personal Hygiene)

Homecare for a Veteran or Surviving Spouse

When did the Veteran serve?

Did the Veteran serve over 90 days: Yes No

Who is the loved one that you are interested in getting information regarding eldercare services?

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

Please provide the following information about your loved one.

Gender: Male Female Age:

What, if any, existing medical conditions does your loved one have?

ALS

Incontinence

Alzheimer's / Dementia

Joint Replacement

Ambulatory Problems

Macular Degeneration / Low Vision

Arthritis

Other Eye Disorders & Diseases

Cancer

Osteoporosis

Colostomy

Parkinson's

Depression

Respiratory Disease

Diabetes

Stroke

Hearing Impaired

Surgical Recovery

Heart Disease

Disease or Condition Not Listed

Quadriplegic

None / Unsure

Which of the following best describes your loved one’s current living arrangement? (Please select one)

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

Do you need or want any of the following Consulting / Advisory Services? (Select all that apply)

Geriatric Care Management	Certified Senior Advisor
Legal / ElderLaw Services	Senior Financing Options (e.g., Reverse Mortgages, Life Settlements, etc.)

What funding source will you be using as the primary payer for the services? (Please select one)

Private pay	Long Term Care Insurance
Veterans Benefits

How much have you budgeted for these "out-of-pocket" expenses? (Please select one)

Less than $250 per week	$1,001 to $1,500 per week
$250 to $500 per week	Over $1,500 per week
$501 to $1,000 per week

Please indicate the number of hours of support services that you estimate your loved one will require. (Please select one)

4 hours/day a couple of times a week	Live in services
4 hours/day daily	24/7 services
Less than 4 hours/day	Just on the weekends
More than 4 hours/day

How would you describe your loved one's feelings about receiving assistance? (Please select one)

Very Receptive	Resistant to Help
No Preference	Somewhat Receptive
We have not discussed it yet

Please include any additional information that you think may be helpful.

To help us to better serve your home care needs, you can provide additional information about your loved one's needs.

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More about Senior Care and In Home Assisted Living Service from Visiting Angels in Rockford-IL!

If you wish to learn more about the Senior care and In Home Assisted Living Services offered by the Visiting Angels Rockford Franchise located in Rockford, Illinois for Serving Rockford, Belvidere, Cherry Valley, Loves Park and Surrounding Cities throughout Boone and Winnebago Counties, IL and other surrounding areas, you can Contact Us or you can Call Us at 1-800-365-4189. We would love to hear from you.