Please complete the form below to begin the application process
Fields marked with a * are required.

Getting Started

Total Care Getting Started Form

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.