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Novalyn Home Care
980-374-4555
info@novalynhomecare.com
Winston-Salem, NC 27105
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I am an North Carolina resident
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Yes
No
Who Needs Care at Home?
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My Self
Parent
Grand Parent
Other Relative
Friend
Other
How Old is the Person Who Needs Care?
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45-54
55-64
65-74
75-84
85 or Elder
Male or Female?
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Male
Female
What is their current living situation?
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Living Alone at Home
Living at Home with Family
In the Hospital Needs a Sitter
In the Hospital Discharging to Home
Assisted Living
Independent Senior Living
Estimate How Much Care They Might Need
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A few Hours a Week
More than 20 Hours per Week
40 or More Hours Per Week
Around-The-Clock-Care
Live-In Care
What type of Care is Needed? (Check all that apply)
Light Meal Preparation
Light Laundry
Light Housekeeping
Companionship
Transportation to Appointments
Grocery Shopping
Errands
Bathing
Toileting
Medication Reminders
Respite Care
How will care be paid for?
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Private Funds
Long-Term Care Insurance
Medicaid
Other
Zip Code Where Care is Needed
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