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 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.
