Health Care Group
Email Us: admin@qhcg.org
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Home
About Us
Services
Apply For Care
OLTL
Long Term Living Program
PA Medicaid Waiver Program
Careers
News
Home
About Us
Services
Apply For Care
OLTL
Long Term Living Program
PA Medicaid Waiver Program
Careers
News
Get Started
Apply For Care
Patient Service Request Form
Who needs care?
*
Parent
Parent
Self
Spouse/Partner
Child
Other
How Old is the Person Who Needs Care?
*
45-54
Under 18
18–24
25–34
35–44
45–54
55–64
65+
Male or Female?
*
Male
Female
Non-binary/Other
Prefer not to say
Current Living Situation
*
Living Alone At Home
Living Alone at Home
Living at Home with Family
In the Hospital
In the Hospital Discharing to Home
Assissted Living
Independent Senior Living
Nursing Home
Other
Estimate of Care Hours per Week?
*
A Few Hours Per Week
A Few Hours Per Week
More Than 20 Hours Per Week
40 Or More Hours Per Week
Live-In Care
Type of Care Needed? (Check all that apply)
*
Bathing/Showering And Grooming Assistance
Toileting And Incontinence Care
Medication Reminders
Light Meal Preparations
Errands/Shopping/Pharmacy
Light Housekeeping
Light Laundary
Companionship
Escort On Appointments ( Doctor's Office And Hair Saloon, etc.,
Safety Supervision
Hospice Care
Respite Care
Alzheimer And Dementia Care
Other
How Will Care be Paid for?
*
Private Funds
Private Funds
Long-Term Care Insurance
Veterans Benefits
Insurance (Private, Medicare, Medicaid)
Other
First Name
*
Last Name
*
Email Address
*
Phone
*
ZIP/ Postal Code
*
How Did You Hear about Us?
*
Schedule Time with Us
Time
Hours
Minutes
AM/PM
AM
PM
Submit
