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Which Service Do I Need?
Step 1 of 2
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Choosing the right health care service for yourself or a loved one can be challenging. With that in mind, Liberty HomeCare & Hospice Services has developed this short questionnaire to help you determine what may be the right choice.
How often does the patient need care?
*
Continuous
No more than a few hours a day
Is the patient's condition life-limiting?
*
Yes
No
Does the patient need any medical treatment?
*
Yes
No
Does the patient need assistance with daily living activities such as bathing, preparation of foods, medication monitoring or housekeeping?
*
Yes
No
Would the patient benefit from companionship, an escort to appointments, or someone to look out for them in the home?
*
Yes
No
Is the patient's condition life-limiting?
*
Yes
No
Is the patient homebound? (needs assistance in walking or leaving their home)
*
Yes
No
Does the patient prefer to stay in their own home?
*
Yes
No
Would the patient prefer help with personal services, such as bathing or having meals prepared for them?
*
Yes
No / Not Sure
Would the patient benefit from companionship, an escort to appointments, or someone to monitor them in their home?
*
Yes
No
Would the patient prefer living in a social setting with others of similar ages and backgrounds?
*
Yes
No
Would the patient benefit from companionship, an escort to appointments, or someone to monitor them in their home?
*
Yes
No
Does the patient have a new medical condition, exacerbation of a previous medical condition, recent fall or recent surgery?
*
Yes
No
Would the patient benefit from additional medical equipment or home infusion treatment?
*
Yes
No
Would the patient benefit from services such as physical therapy, speech therapy, or occupational therapy?
*
Yes
No / Not Sure
Would the patient benefit from additional home medical equipment or home infusion treatment?
*
Yes
No
Would the patient benefit from telemonitoring, advanced wound care, or other similar treatments?
*
Yes
No / Not Sure
Would the patient benefit from additional home medical equipment or home infusion treatment?
*
Yes
No
Would the patient benefit from additional home medical equipment or home infusion treatment?
*
Yes
No / Not Sure
*
= This is a required field
Before we proceed, tell us a little about yourself.
I’m interested in care for:
*
Family Member
Friend
Myself
Other
I’m seeking care in:
*
North Carolina
South Carolina
Virginia
Other
I’m seeking care in zip code:
*
Name
*
First
Last
Email
Phone
*
Name of Person Requiring Care
*
First
Last
Please let us know how we can help:
*
= This is a required field
Refer A Patient
Home Care Needs Assessment
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