About the person needing care Who needs care?* Select oneMyselfParent or relativeVeteranClient or patient referral Care recipient's age range Select oneUnder 6060–6970–7980–8990+ City or ZIP code where care is needed* Living situation Select oneLives aloneLives with spouseLives with family caregiverAssisted or shared settingOther Care needs Primary assistance needed* Select oneBathing, dressing or groomingMobility and transfersMeal preparationMedication remindersCompanionship and safety monitoringRespite for a family caregiverStructured Family CaregivingVA-supported home careUnsure — please guide me When is care needed?* Select oneImmediatelyWithin 1–2 weeksWithin 30 daysPlanning ahead Preferred schedule Weekday daytimeEveningsOvernightWeekendsLive-in family caregivingNot sure Coverage and program interest Potential payment source Select onePrivate payIndiana Medicaid / PathWaysVA benefitsLong-term care insuranceUnsure Is the person currently enrolled in Indiana Medicaid? YesNoUnsure Is the person a Veteran? YesNo Your contact information Your name* Relationship to the person needing care Phone number* Email address* Best time to contact MorningAfternoonEvening How did you hear about White Oak? Select oneGoogle Search or MapsFacebookYouTubeHospital or rehabilitation facilityDoctor or health care professionalVA or Veterans organizationIndiana PathWays or Medicaid planFamily or friendCommunity organization or eventOther Briefly describe the situation Please do not submit Social Security numbers, Medicaid or VA identification numbers, financial account details, or medical records through this form. I authorize White Oak Home Care to contact me about this inquiry. I understand that submitting this form does not guarantee eligibility, coverage, authorization or service availability.
