Getting Started

Thank you for your interest in our services.  An agency representative will contact you shortly to discuss a care plan that is committed to Caring For You Like Family.

Who is in need of care? *

Infant/Toddler (0 - 4 years old) Child (4 - 18 years old) Adult Female (19 - 64 years old) Adult Male (19 - 64 years old) Senior (65+)

Name of person needing care? *

What is your relationship to the person needing care? *

Me My Sibling My Parent My Child Other  

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Where will they need to receive care? *

Connecticut

What town does the person who needs care live in? *

What type of home/housing do they have? *

Select One: Single-Family Home Multi-Family Home Apartment Building Independent Living Facility Assisted Living Facility

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What type of care do they need? * (Check all that apply.)

Type of Care Needed

Skilled Care (Nurses, Therapists, Social Workers) Licensed Care (Certified Nurses Aides, Home Health Aides, Live-In Aides) Non-Skilled Care (Companions, Personal Care Aides, Homemakers) Assisted Living Services

Conditions

Alzheimer's Disease/Dementia An Accident (e.g., fall, injury, etc) Cancer Chronic Pain Diabetes Heart Disease High Blood Pressure Hospital Care Knee/Hip Replacement Pulmonary Disease Stroke/Other Brain Injury Wounds None of the Above

General Assistance Needs

House Cleaning (routine or seasonal) Hospital or Facility Sitting Services Meal Preparation Medication Reminders Shower Assistance Patient Advocate Senior Advisor Services Cancer

Additional comments regarding type of care needed?

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What type of health insurance do they have or are eligible for?
(Check all that apply.)

Private Pay / Fee-for-Service Medicaid Medicare Private / Commercial Insurance (Anthem Blue Cross & Blue Shield, Humana, United Health Care, etc.) Long-Term Care Insurance Policy Worker's Compensation Insurance None Not Sure

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How soon will care need to begin?

Immediately This Week This Month In the Next Few Months Not Sure

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How can we contact you?

Your Name *
Street Address *	City *
State * Zip *	Email *
Cell Phone	Home Phone
Best Available Phone * cell home other
I would like to receive news and updates from Utopia.

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How would you like to speak with a Utopia representative? *
(Check all that apply.)

By phone In person at a facility where I or my loved one is currently receiving care In person, in the comfort of my own home

What is the best time of day for an agency representative to contact you by phone? *(Check all that apply.)

Early morning before 9:00 a.m. Mid-late morning (9:00 a.m. - Noon) Lunch-time (Noon - 1:30 p.m.) Afternoon (1:30 p.m. - 5:00 p.m.) Evening (5:00 p.m. - 9:00 p.m.)

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