1. Please select your county name:  ( required )	Alcorn Anne Arundel Autauga Baldwin Barbour Bay Bibb Blount Bullock Butler Calhoun Catoosa Chambers Cherokee Chilton Choctaw Clarke Clay Cleburne Cobb Coffee Colbert Conecuh Coosa Covington Crenshaw Cullman Dade Dale Dallas DeKalb Elmore Escambia Etowah Fayette Franklin Fulton Geneva Giles Gordon Greene Gwinnett Hale Hardin Harrison Henry Hillsborough Hot Spring Houston Irriqusine Jackson Jasper Jefferson Jones Lamar Lauderdale Lawrence Lee Limestone Lincoln Lowndes Macon Madison Marengo Marion Marshall McNairy Mercer Middlesex Mobile Monroe Montgomery Morgan Muscogee Out of state Perry Pickaway Pickens Pike Randolph Richmond Russell Rutherford Santa Rosa Shelby St. Clair Sumter Talladega Tallapoosa Thurston Tishamingo Troup Tuscaloosa Walker Washington Wayne Wilcox Winston
2. Please select surrounding county name (optional):
3. Please select the kind of service you wish to receive  ( required )
In my home	In the community
At a residential facility	In an institutional setting
I'm not sure
4. I require assistance with the following tasks:
Eating	Dressing/Grooming
Toileting	Transferring (bed to chair or wheelchair)
Bathing	Medication reminders or supervision
5. I require assistance with the following household chores:
Cooking	Shopping
Telephone calls	Money management
Transportation	Light cleaning
Heavy cleaning
6. My mobility level is such that:
I walk without assistance	I use a cane or walker
I use a wheelchair	I am bedridden
7. I have experienced symptoms such as:
Confusion about where I am	Forget names of family members or friends
8. In my current situation, I have:
Care needs which are often unmet	I am left alone for more then 24 hours
Insufficient opportunities to socialize	Family and friends that do not live close enough
Generally sufficient care for my needs
9. I am able to pay for services out of my own pocket:
Entirely	Somewhat
Not at all	I don't know
10. My health insurance is issued by:
The Veterans Administration	Medicaid
Medicare	Long-term care insurance
Other	I am not insured
11. I have the following medical condition:
Alzheimer's disease or Dementia	Brain injury
Cancer	Stroke
Pulmonary (lung) disease	Heart problems
Diabetes	Recovering from surgery/infection or injuries
Parkinson's disease	Multiple Sclerosis
Developmental Disability	HIV/AIDS
Arthritis	Depression
Psychiatric illness
12. My 2 or 3 most pressing needs are:
Food	Housing
Daily living assistance	Skilled nursing care
Social and recreational activities	Rehabilitation (surgery, accident, stroke, etc.)
Transportation	Assistance in developing a plan of care
Grief Support	Companionship
Adult/Senior abuse