Use this worksheet to record information when investigating which agencies and facilities provide long-term care services in your area (or in the area where you would be most likely to receive care) and what the costs are for these services.

Home Health Agency
Name of one Home Health Agency you
might use _________________________
_________________________________
Name of another Home Health Agency you
might use _________________________
_________________________________
Address __________________________
_________________________________
_________________________________
Address __________________________
_________________________________
_________________________________
Phone number _____________________Phone number _____________________
Contact Person _____________________Contact Person _____________________

Check which types of care are available and list the cost
Skilled Nursing Care
Cost/Visit $______________________
Skilled Nursing Care
Cost/Visit $______________________
Home Health Care
Cost/Visit $______________________
Home Health Care
Cost/Visit $______________________
Personal/Custodial Care
Cost/Visit $______________________
Personal/Custodial Care
Cost/Visit $______________________
Home Care Services
Cost/Visit $______________________
Home Care Services
Cost/Visit $______________________

Nursing Facility
Name of one Nursing Facility
_________________________________
Name of another Nursing Facility
_________________________________
Address __________________________
_________________________________
_________________________________
Address __________________________
_________________________________
_________________________________
Phone number _____________________Phone number _____________________
Contact Person _____________________Contact Person _____________________



Check which types of care are available and list the cost
Skilled Nursing Care
Cost/Month $______________________
Skilled Nursing Care
Cost/Month $______________________
Personal/Custodial Care
Cost/Month $______________________
Personal/Custodial Care
Cost/Month $______________________

Other Facility

Other Facility or Service you might use
(e.g. adult day care center, assisted living, etc.)
_________________________________
Other Facility or Service you might use
(e.g. adult day care center, assisted living, etc.)
_________________________________
Address __________________________
_________________________________
_________________________________
Address __________________________
_________________________________
_________________________________
Contact Person _____________________Contact Person _____________________
What services are available?
_________________________________
_________________________________
_________________________________
What services are available?
_________________________________
_________________________________
_________________________________
What are the costs for these services?_________________________________What are the costs for these services?_________________________________