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 AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

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.

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