Home
Assistance
Learn More
For Employers
Webinars
Contact Us
Open A Case
Please complete this form to open a case or request assistance.
*Required Fields
Employer
*
Cannon & Company, LLP
Family Services
High Point University
Piedmont Federal Savings Bank
Salem Academy & College
Senior Services, Inc.
Smart Start of Forsyth
Summit School
Trellis Supportive Care
Wake Forest University
Wake Forest University Health Sciences
Womble Bond Dickinson, LLP
Women's Health Alliance of the Piedmont
Work Family Resource Center
Location (city, state)
*
Name
*
First
Last
Address
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
County
Email
*
Phone
How would you like the ECC counselor to contact you between the hours of 8am-4pm?
*
Email
Phone
Person you are Contacting Us About
If other than yourself.
Relationship to You
Gender
*
Male
Female
Age
*
Birthdate (if known)
MM slash DD slash YYYY
Name
First
Last
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
County
Phone
Please answer the following questions about the person needing assistance.
Is He/She
Married
Divorced
Widowed
Single (Never Been Married)
Is He/She a Veteran
Yes
No
Monthly Income (if known)
Insurance
Medicare
Medicaid
Other
Other Insurance
Is he/she married to or a widow of a Veteran?
Yes
No
Is he/she disabled?
Yes
No
Does this person have Dementia?
Yes
No
Please Describe Dementia Related Behaviors
What diagnosis does this person have or has had in the past that affect their current need or situation:
This person needs assistance with: (check all that apply)
Walking
Bathing
Dressing
Eating
Toileting
Transferring
Housework
Meal Prep
Medication Use
Money Management
Using the Telephone
Shopping
Transportation
Tell us what you need assistance with:
Please be advised that the names of providers are referrals only, not recommendations. The providers themselves supply the information contained in the referrals. We do not endorse any particular provider or assume any liability or responsibility as a result of any referral. We make every effort to provide you with up-to-date information; however, the information is subject to change. Since selecting a provider is a subjective decision, you should check facilities, programs and references to evaluate the best arrangement for your loved one and your family.
Back to Top