Please check all that apply:

• I am currently being treated by a doctor for an illness or injury
• All treatments for my illness have been stopped even though I have not recovered
• My doctor informed me that I have 6 months or less to live
• I want help with housekeeping tasks, laundry or shopping
• I need someone to stay with me for 4 or more hours at a time
• My illness, injury, or disability prevents me from leaving my home without help