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Senior Home Care Agency – caregiving agencies

Please fill out the form below to receive quotes on rates and services from quality, licensed home care agencies in your area. Note: Address of Care location is required to Connect you with Quality Agencies serving your area. Your information will be kept confidential to the Senior Home Care Agencies serving this area – if for any reason you want to maintain confidentiality of the care address, submit “100 Main Street” as the street address and then submit the correct city, state and zip-code to be matched properly with agencies serving your area.

Title:
First Name:
Last Name:

Address:

City:
State:
ZIP Code:

If you prefer to be contacted by e-mail, rather than telephone, you may leave the telephone fields blank.

Daytime Phone:	() -
Evening Phone:	() -
Best Time to Call:

Email Address:
Confirm:

Care Location:	Care will be provided at the above address Care will be provided at a different address

Who will be needing the senior care services?

Mother
Mother-in-law
Father
Father-in-law
Spouse
Sibling
Other Relative
Self
Friend

What is the age of the oldest senior needing in-home care?

Under 65
66 - 80
81 - 90
91+

How receptive is the senior to receiving care?

Very Receptive: senior recognizes care is needed and welcomes caregiving
Somewhat Receptive: senior recognizes care is needed but has some concerns
Unreceptive: senior has refused to discuss care needs or forgets care has been discussed

Type of care:

close X
Senior Home Care Agencies provide hourly care or live-in care. Hourly care usually requires a minimum of at least 3 to 4 hours of care services per visit. Live-in care provides for a caregiver around-the-clock who prepares meals and eats with the senior and sleeps in the home. If a senior is unable to sleep at night and needs a caregiver who is awake around-the-clock, hourly care would be required, with different caregivers working day and night shifts.

	Private-pay hourly care close X Hourly, minimum of 3 or 4 hours per visit
	Private-pay Live-in care close X 24-hour care, Caregiver works during the day and sleeps at night and typically 2 caregivers will rotate during the week.
	No funds to private pay and no long-term care insurance close X Medicaid, for low-income seniors, pays for care in a nursing home and only a few states have Medicaid programs providing for home caregivers. Additional information on Medicare and Medicaid
	Both Private-pay Hourly and Private-pay Live-in Care

Request information from agencies serving your area who charge:

$16 - $20 per hour
$21 - $25 per hour
All

Note: Some agencies require a retainer fee equal to 2-weeks of care services to begin staffing a new case. Medicare and Medicaid do NOT pay for long-term senior care in the home.

When do you anticipate starting care services?

Immediately (hospital or nursing home discharge, hospice starting or sudden change in medical conditions)
Within 1 month
Within 6 months
Temporary respite care
Researching for future needs

To assist us to more efficiently connect you with the most appropriate care services, please indicate the following needs:

	Alzheimer's Disease/Memory Loss
	Ambulation (unable to walk unassisted)
	Dressing
	Bathing
	Toileting
	Meal Preparation
	Eating Assistance
	Laundry
	Housekeeping
	Exercises/Activities
	Medication reminders
	Escort to appointments
	Companionship
	Other Special Care Needs or Requirements:

Please indicate the living situation of the care recipient:

Lives in own home
Lives with family member
Lives in Senior Apartment
Lives in Assisted Living Community
Lives in Nursing Home
Currently Hospitalized

Please confirm the type of payment for the in-home senior care services.

Either private payment or long-term care insurance or worker’s compensation insurance is required by Senior Home Care Agencies:

Private Pay
Long-term care insurance
Worker’s compensation insurance
No funds to private pay and no long-term care insurance, seeking Medicaid options

Will you be considering an Assisted Living or Continuing Care Community as a living option at some point?

Check here if you would like Caregiverlist’s information on Assisted Living costs, services and availability in your area.

I have read and agree to these terms and conditions:

Effective Date:  This Terms of Use Agreement was last updated on February 5, 2008.
 

Caregiverlist, Inc. (“Caregiverlist”) is an Illinois Corporation. This Terms of Use Agreement (“Agreement”) sets forth the standards of use of Caregiverlist’s website (referred to herein as “Caregiverlist.com”, the “Caregiverlist website” and/or the “website”). By using Caregiverlist.com and its related pages, you (the “User”) agree to these terms and conditions. If you do not agree to the terms and conditions of this agreement, you should immediately cease all usage of this website. We reserve the right, at any time, to modify, alter, or update the terms and conditions of this agreement without prior notice.  Modifications shall become effective immediately upon being posted at Caregiverlist.com.  Your continued use of the Caregiverlist.com after amendments are posted constitutes an acknowledgement and acceptance of the Agreement and its modifications. Except as provided in this paragraph, this Agreement may not be amended.

1.         Description of the Caregiverlist website and services

By use of Caregiverlist.com, Caregiverlist is providing User with senior care information and contacts. User must provide (1) all equipment necessary for their own Internet connection, including computer and modem and (2) provide for User’s access to the Internet, (3) pay any fees that relate with such connection and (4) pay any fees that Caregiverlist states users must pay to use its website, related links and services (when applicable). 

2.         Disclaimer of Warranties.

The information and any opinions contained herein should not be relied upon by you without actual consultation with the appropriate professional and/or licensed medical care provider. Specialized individual assessment and evaluation is often times necessary where senior care is sought. To the fullest extent permitted by applicable law, Caregiverlist makes no representations or warranties of any kind, express or implied, regarding the use or the results of this website in terms of its correctness, accuracy, reliability, or otherwise.  Caregiverlist shall have no liability for any interruptions in the use of this website.  Caregiverlist disclaims all warranties with regard to the information provided, including the implied warranties of merchantability and fitness for a particular purpose, and non-infringement. 

YOU UNDERSTAND AND AGREE THAT IF YOU DOWNLOAD OR OTHERWISE OBTAIN MATERIALS, INFORMATION, PRODUCTS, SOFTWARE, PROGRAMS, OR SERVICES, YOU DO SO AT YOUR OWN DISCRETION AND RISK AND THAT YOU WILL BE SOLELY RESPONSIBLE FOR ANY DAMAGES THAT MAY RESULT, INCLUDING LOSS OF DATA OR DAMAGE TO YOUR COMPUTER SYSTEM.

SOME JURISDICTIONS DO NOT ALLOW THE EXCLUSION OF WARRANTIES, SO THE ABOVE EXCLUSIONS MAY NOT APPLY TO YOU.

3.         Limitation of Liability.

The hiring of a senior care provider is an important decision that should not be based solely upon this communication or the information provided on the Caregiverlist website. The information contained in this website is for informational purposes only.  Nothing in the Caregiverlist website should be construed as giving medical, assisted living and/or, where appropriate, legal advice.  The providing of material contained on this website is not intended to create and receipt of it does not create liability upon Caregiverlist, its employees, consultants, website content providers and/or its partners.

CAREGIVERLIST SHALL NOT be liable for any damages whatsoever, and in particular Caregiverlist shall not be liable for any special, PUNITIVE, indirect, COMPENSATORY, consequential, or incidental damages, or damages for PERSONAL INJURY, WRONGFUL DEATH, LOST profits, loss of revenue, or loss of use, arising out of or related to this web site or the information contained in it, whether such damages arise in contract, negligence, tort, under statute, in equity, at law, or otherwise, even if Caregiverlist has been advised of the possibility of such damages. SOME JURISDICTIONS DO NOT ALLOW FOR THE LIMITATION OR EXCLUSION OF LIABILITY FOR INCIDENTAL OR CONSEQUENTIAL DAMAGES, THEREFORE SOME OF THE ABOVE LIMITATIONS IS INAPPLICABLE.

4.         Indemnification.

User agrees to indemnify and hold Caregiverlist, its parents, subsidiaries, affiliates, consultants, website content providers, officers and employees, harmless from any claim or demand, including reasonable attorneys’ fees and costs, made by any third party due to or arising out of User’s use of Caregiverlist.com, the violation of this Agreement, or infringement by User, or other user of Caregiverlist.com using User’s computer and/or logon information, of any intellectual property or any other right of any person or entity.

5.         Modifications and Interruption to the Caregiverlist website.

Caregiverlist reserves the right to modify or discontinue Caregiverlist.com with or without notice to the User. Caregiverlist shall not be liable to User or any third party should Caregiverlist exercise its right to modify or discontinue Caregiverlist.com. User acknowledges and accepts that Caregiverlist does not guarantee continuous, uninterrupted or secure access to our website and operation of our website may be interfered with or adversely affected by numerous factors or circumstances outside of our control.

6.         Third-Party Sites.

Our website may include links to other sites on the Internet that are owned and operated by online merchants and other third parties.  You acknowledge that we are not responsible for the availability of, or the content located on or through, any third-party site.  You should contact the site administrator or webmaster for those third-party sites if you have any concerns regarding such links or the content located on such sites.  Your use of those third-party sites is subject to the terms of use and privacy policies of each site, and we are not responsible therein. We encourage all Users to review said privacy policies of third-parties’ sites.
7.         Linking to this Site

All links to this Web site must be approved in writing by Caregiverlist, except that Caregiverlist consents to links in which the link and the pages that are activated by the link do not: (a) create frames around any page on this Web site or use other techniques that alter in any way the visual presentation or appearance of any content within this site; (b) misrepresent your relationship with Caregiverlist; (c) imply that Caregiverlist approves or endorses you, your Web site, or your service or product offerings; and (d) present false or misleading impressions about Caregiverlist or otherwise damage the goodwill associated with the Caregiverlist name or trademarks. As a further condition to being permitted to link to this site, you agree that Caregiverlist may at any time, in its sole discretion, terminate permission to link to this Web site. In such event, you agree to immediately remove all links to this Web site and to cease using any Caregiverlist trademark.

8.         Disclaimer Regarding Accuracy of Service Provider Information.

Information has either been provided by Service Providers or collected from publicly available sources.  While Caregiverlist makes every effort to ensure that the information on this website is accurate, we can make no representations or warranties as to the accuracy or reliability of any information provided on this website.

Caregiverlist makes no warranties or representations whatsoever with regard to any service and/or product provided or offered by any Third Party, and you acknowledge that any reliance on representations and warranties provided by any Third Party shall be at your own risk.

9.         Governing Jurisdiction of the Courts of Illinois.

Our website is operated and provided in the State of Illinois.  As such, we are subject to the laws of the State of Illinois, and such laws will govern this Terms of Use, without giving effect to any choice of law rules.  We make no representation that our website is appropriate, legal or available for use in other locations.  Accordingly, if you choose to access our site you agree to do so subject to the internal laws of the State of Illinois. 

10.       Compliance with Laws.

User assumes all knowledge of applicable law and is responsible for compliance with any such laws.  User may not use Caregiverlist.com or the content therein in any way that violates applicable state, federal, or international laws, regulations or other government requirements. User further agrees not to transmit any material that encourages conduct that could constitute a criminal offense, give rise to civil liability or otherwise violate any applicable local, state, national, or international law or regulation.

11.       Content.

Caregiverlist receives compensation from certain third parties to list their services and/or provide consensual leads to Users of the Caregiverlist website. The services and products listed on the Caregiverlist website are sold or provided by third parties, and are not sold or provided by Caregiverlist.

Caregiverlist does not sell, resell or license any services and/or products listed on the Caregiverlist website, nor is Caregiverlist acting as an agent of sale. Caregiverlist disclaims any responsibility for, or liability related to, such services and/or products (see Disclaimer of Warranties below). Any question, complaints or claims should be directed to the appropriate merchant or service provider.

Caregiverlist does not warrant the content of the Caregiverlist website, regardless of its source, is accurate, complete, reliable, current or error-free. The Caregiverlist website content is provided for informational purposes only and does not constitute an endorsement by Caregiverlist of any service provider. You should not rely on such information in situations where its inaccuracy would cause you to suffer any loss (see Disclaimer of Warranties and Limitation of Liability above). Caregiverlist assumes no liability for inaccuracy or incompleteness in its search results, editorial content or other content on the Caregiverlist website.

Comments, reviews and ratings (collectively referred to as “postings”) on the Caregiverlist website are from our Users who have elected to post their opinions and/or experience on the Caregiverlist website. As such, these postings are informative for those wishing to use them, but they do not guarantee or ensure any level of performance of any given service provider.

You may download, view and print a single copy of any content, solely for your personal and non-commercial purposes, subject to the restrictions set forth in this Agreement. All right, title, and interest in and to the Caregiverlist website, and any other content appearing on the Caregiverlist website, will remain the exclusive property of Caregiverlist and its licensors. Except as expressly permitted in this Agreement, you may not reproduce, modify or prepare derivative works based upon, distribute, sell, transfer, publicly display, publicly perform, transmit, or otherwise use the Caregiverlist website, or any other content appearing on the Caregiverlist website. You may not copy or modify the HTML code used to generate web pages on the Caregiverlist website. You may not use the Caregiverlist website, or any other content appearing on the Caregiverlist website, on or in connection with any other website, for any purpose.

12.       Content Submission.

By contributing or submitting any content to the Caregiverlist website, you warrant that you are the author and owner of the intellectual property rights thereto, and you grant Caregiverlist a worldwide, perpetual, irrevocable, royalty-free, transferable right and license to use, copy, modify, delete in its entirety, adapt, publish, translate, create derivative works from and/or sell and/or distribute such materials and/or incorporate such materials into any form, medium or technology without compensation to you. In addition, you warrant that all "moral rights" that you may have in those materials have been voluntarily waived by you. None of the materials shall be subject to any obligation of confidence on the part of Caregiverlist, its agents, subsidiaries, affiliates, co-brand partners or other partners and their respective directors, officers, consultants and employees. Caregiverlist reserves the right to change, condense or delete any content on the Caregiverlist website that Caregiverlist deems, in its sole discretion, to violate the content guidelines or any other provision of this Agreement.

Without limiting the foregoing, you agree that you will not use our sites to take any of the following actions:

   1. Defame, abuse, harass, stalk, threaten, or otherwise violate the legal right of others;
   2. Publish, post, upload, e-mail, distribute, or disseminate (collectively, "Transmit") any inappropriate, profane, defamatory, infringing, obscene, indecent, or unlawful content;
   3. Transmit files that contain viruses, corrupted files, or any other similar software or programs that may damage or adversely affect the operation of another person's computer, our sites, any software or hardware, or telecommunications equipment;
   4. Advertise or offer to sell any goods or services for any commercial purpose unless you have our written consent to do so;
   5. Transmit surveys, contests, pyramid schemes, spam, unsolicited advertising or promotional materials, or chain letters;
   6. Download any file that you know or reasonably should know cannot be legally obtained in such manner;
   7. Falsify or delete any author attributions, legal or other proper notices or proprietary designations or labels of the origin or the source of software or other material;
   8. Restrict or inhibit any other user from using and enjoying any public area within our sites;
   9. Collect or store personal information about other end users;
  10. Interfere with or disrupt our sites, servers, or networks;
  11. Impersonate any person or entity, including, but not limited to, a Caregiverlist representative, or falsely state or otherwise misrepresent your affiliation with a person or entity;
  12. Forge headers or manipulate identifiers or other data in order to disguise the origin of any content transmitted through our sites or to manipulate your presence on our sites;
  13. Take any action that imposes an unreasonably or disproportionately large load on our infrastructure;
  14. Engage in any illegal activities.

In addition, you agree to comply with Caregiverlist’s website rules which are deemed to be incorporated into this Agreement.

You retain all ownership rights to information, text, graphics, or other materials you publish on the Caregiverlist website. However, you grant us an irrevocable right and license to reproduce, publish and distribute all or any portion of your content online and offline and permit others to do the same. You can edit or remove your content from the Caregiverlist website at any time; but if we have distributed your content to others, we may be unable to require them to make the same changes.
13.       Account Termination Policy

            Caregiverlist will terminate a User's access to its Website if, under appropriate circumstances, they are determined to be a repeat infringer.  Caregiverlist reserves the right to decide whether Content or a User Submission is appropriate and complies with these Terms of Service for violations other than copyright infringement, such as, but not limited to, obscene or defamatory material, or excessive length. Caregiverlist may remove such User Submissions and/or terminate a User's access for uploading such material in violation of these Terms of Service at any time, without prior notice and at its sole discretion.

14.       Copyrights.

All content available on the Caregiverlist website, including site design, text, graphics, interfaces, and the selection of arrangements thereof is copyrighted by Caregiverlist, with all rights reserved, or is the property of third parties protected by intellectual property rights. Caregiverlist’s marks/trademarks may not be used in connection with any product or service that is not provided by the Caregiverlist website, in any matter that is likely to cause confusion among customers, or in any manner that disparages or discredits Caregiverlist. If you believe content on the Caregiverlist website infringes your copyright, you should send notice of copyright infringement to Caregiverlist’a Copyright Agent. Your notice must meet the requirements of the Digital Millennium Copyright Act (as required under 17 U.S.C. §512) by providing the following information:

1. An identification of the copyrighted work claimed to have been infringed

2. An identification of the material that you claim is infringing so that we may locate it on the site

3. Your address, telephone number and email address

4. A statement by you that you have a good-faith belief that the disputed use is not authorized by the copyright owner, its agent or the law

5. A statement by you that the above information in your notice is accurate, made under penalty of perjury, and that you are authorized to act on behalf of the owner of the copyright interest involved

6. Your signature

The notice should be mailed to the agent set forth in Section 15 below.  Upon receipt of notice as described above, Caregiverlist will take whatever action, in its sole discretion, it deems appropriate, including removal of the challenged content from the Caregiverlist website.

15.       Notification of Claimed Copyright Infringement.

Pursuant to Section 512(c) of the Copyright Revision Act, as enacted through the Digital Millennium Copyright Act, caregiverlist.com designates the following individual as its agent for receipt of notifications of claimed copyright infringement.

By Mail:

Caregiverlist, Inc.
P.O. Box 10762
Chicago, IL 60610
By Email: Support@Caregiverlist.com
 

16.       Other Terms.

If any part of these Terms is determined to be invalid or unenforceable pursuant to applicable law, then the invalid or unenforceable provision will be deemed superseded by a valid, enforceable provision that most closely matches the intent of the original provision and the remainder of the Terms shall continue in effect.

You agree that this Terms of Use Agreement and any other agreements referenced herein may be assigned by Caregiverlist, in our sole discretion, to a third party in the event of a merger or acquisition. 


This Terms of Use Agreement shall apply in addition to, and shall not be superseded by, any other written agreement between us in relation to your participation as a User. 
 

User agrees that by accepting this Terms of Use Agreement, User is consenting to the use and disclosure of their personally identifiable information and other practices described in our Privacy Policy.

Our failure to exercise or enforce any right or provision of these Terms shall not constitute a waiver of such right or provision.

You agree that regardless of any statute or law to the contrary, any claim or cause of action arising out of or related to use of our sites or these Terms must be filed within one (1) year after such claim or cause of action arose or be forever barred.

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