Online Evaluation

Helping you through the process.

Navigating the information and decisions around in-home care can be confusing and stressful, so Accordance works with you to explain our services and determine exactly what you do and do not need. To help us get better acquainted with your situation, please fill out this simple online evaluation form:

Has your loved one fallen recently?

 Yes No

Are you worried about the risk of a loved one falling?

 Yes No

Do you regularly remind your loved one to bathe, eat meals, dress, or take medication?

 Yes No

Is your loved one suffering from memory loss or forgetfulness?

 Yes No

Does your loved one require constant monitoring?

 Yes No

Have they recently needed to visit the emergency room?

 Yes No

Have they recently (in the past six months) been hospitalized?

 Yes No

Do you require immediate help in your particular circumstance?

 Yes No

Does your loved one require occupational or physical therapy?

 Yes No

Your Name:

Email Address:

Telephone Number:

I prefer to be contacted:

During the dayIn the evening

How did you hear about us?

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