1. Please select your county name:  ( required )	Autauga Baldwin Barbour Bibb Blount Bullock Butler Calhoun Chambers Cherokee Chilton Choctaw Clarke Clay Cleburne Coffee Colbert Conecuh Coosa Covington Crenshaw Cullman Dale Dallas DeKalb Elmore Escambia Etowah Fayette Franklin Geneva Greene Hale Henry Houston Jackson Jefferson Lamar Lauderdale Lawrence Lee Limestone Lowndes Macon Madison Marengo Marion Marshall Mobile Monroe Montgomery Morgan Perry Pickens Pike Randolph Russell Shelby St. Clair Sumter Talladega Tallapoosa Tuscaloosa Walker Washington 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