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P.O. Box 201056
333 E. Washington Street
Stockton, CA 95202
(209) 468-1000

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Online Assessment

Welcome.

Senior women surfing online.This assessment form allows you to obtain information regarding programs that may be of assistance to someone that you care for, a loved one, or yourself. This is a resource service and does not guarantee eligibility. In order to determine true eligibility, please use the "Contact" button on the following page.

The information you provide is only used to help you research available assistance and information. It is not stored or saved for other purposes.

Note: If you are filling this out for someone else, please be sure to fill in THEIR information on the following questions.

Please complete this short form in order to obtain more information.
The red * indicates required information to provide correct results.

First Name *    Age *    City *

I am filling this information out for: Myself  Someone Else
If for someone else, relationship to you?Family Member  Friend  Patient/Client

Total Personal Monthly Income   $*
Total Household Monthly Income $* (If you live alone, this will be the same.)
Own a Home Yes No
U.S. Citizen Yes No
Legal Immigrant Yes No
Medi-Cal Yes No
Medi-Care Yes No
Number of persons in home 
Do you have a spouse that provides care and is able to assist you? Yes No
Were you recently discharge from a hospital or nursing facility?
    If yes, when (mm/yy)
Yes No

Select your area of needs or interest:

Assistance For Caregivers
I care for someone else, and I need:
Constant Help
Respite Help (Help every now and then so you can go do other things.)

Care For Myself
I'm interested in services for myself:
Constant In-Home Care Housekeeping
Occasional In-Home Care Cooking
Errands Personal Care/Daily Hygiene
Other, specify
 
Is someone helping you now? Yes No
If yes, are they paid? Yes No

Health
I would like additional information on the following items:
Alzheimer's Cancer Diabetes Vision
Dental Rehab General

General
I would like additional information on the following items:
Transportation Legal Financial Support Groups

To see more information, please click here

 

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