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   1. Indicate Name of Agency Below

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4. 1. Name of Agency*
6. 2. Contact name, phone number and email address
8. 3. Website URL:
10. 4. Are you currently taking new residents/clients?

    1. yes
    2. no
11. 5. Lead time for new client intake?
13. 6. Are you currently available for 24 hour care?
15. 7. What (If any) COVID-19 restrictions/issues have you implemented?
17. 9. Charge per hour?
19. 10. Minimum number of hours per week you will come to a client’s home to assist?
21. 11. Do you provide transportation for clients?

    1. yes
    2. no
23. Using the care provider/aide's car?

    1. yes
    2. no
25. 12. If a client needs to attend a doctor’s appointment, are aides available to assist?

    1. yes
    2. no
27. 13. If a client needs to attend an appointment and undergo anesthesia are your employees able to sign for that individual if there is no family to assist?

    1. yes
    2. no
29. 14. Do you have any aides that can speak a language other than English?

    1. yes
    2. no
31. If yes, what language?
33. 15, Do you currently have any aides that know sign language?

    1. yes
    2. no
35. 16. Any additional information?
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37. 1. Receive an email copy of this form.
38. Email address

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39. Submit

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