Please complete the form below to begin the application process Fields marked with a * are required. Getting Started Total Care Getting Started Form If you are human, leave this field blank. First Name * Last Name * Date of Birth * Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona 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 State/Province Zip/Postal Zip/Postal Best Contact Phone Number * Housing Type * Subsidized Private Marital Status * Single Married Divorced Widowed Sex * Male Female Emergency/Guardian Contact Name and Relationship * Emergency/Guardian Contact Phone Number * Please select the services that you are seeking: * Bathing Dressing Eating/Feeding Transferring/Moving Toileting Medication Reminder OtherOther Are you currently receiving services? * Yes No Please check all that apply * Skilled Nursing Adult Foster Care (GAFC) Group Adult Foster Care (GAFC) Private Care Program Home Care Services I am currently receiving Medicaid benefits or I am Medicaid Eligible * Yes No Please review and confirm your information * I understand that I am applying to become a participant or refer a loved one for the (1) Adult Foster Care (AFC) Program, (2) Group Adult Foster Care (GAFC) Program, or (3) Private Care Program (PCP). I certify that to the best of my knowledge the above information is complete and correct.