Request for Assistance

Thank you for connecting with us. Elder Care Choices is an exclusive employee benefit for companies across the country that have contracted to offer this service for their employees in any state. We provide information and referrals to older adults and those who care for them. If your employer does not offer the Elder Care Choices benefit, please go to our Help Line portal for information and referrals in Forsyth County, North Carolina.

So that we may assist you with accurate information, please complete the form below. You can also call Elder Care Choices at (336) 748-2171 or email ecc@seniorservicesinc.org

An Aging Resource Specialist will respond to your request within one business day. The response will come from ecc@seniorservicesinc.org.

Please note: Elder Care Choices does not offer emergency assistance. If you or someone you know is having a medical or mental health emergency, please call 911.

Are you inquiring about Elder Care Choices Notes and/or requesting resource facts sheets? *

Yes

No

What information are you looking for? *

Are you requesting previously recorded webinars? *

Yes

No

Select the webinars you would like: *

Avoiding pitfalls in admissions agreements (long-term care)

Brain Science and Dementia - What you see and why it happens

Help! I'm overwhelmed- Navigating the Medicare enrollment process

Not your everyday caregiver's toolkit - How to be a Healthcare Advocate

The aging brain: What to expect as we get older

Are you inquiring about support for someone? *

Yes

No

Information about you

First Name *

Last Name *

Who is your employer? *

Your Location (city, state) *

Your Home Zip Code *

Email Address *

How would you like to connect? *

Email

Phone

Online (Zoom, Microsoft Teams, Etc)

Please include your preferred email address if different from above:

Phone Number

Information about the person you are contacting us about. Complete as much information as you know.

First Name *

Last Name *

Their Age *

Their Gender *

Female

Male

Other

Prefer not to say

Street Address

Address Line 2

City *

State *

Zip Code

County (if known)

Please answer the following questions about the person who needs assistance:

They are: *

Did they serve in the military?

Yes

No

Are they a widow/widower of someone who served in the military?

Yes

No

Insurance *

Medicare

Medicaid

Group Employer Health Plan

Medicare

Medicare Advantage Plan

Original Medicare (also known as Supplement or Medigap)

Are they disabled? *

Yes

No

Do they have dementia? *

No

Yes

Dementia related behaviors

Do they have a current or previous diagnosis that affects their current need or situation?

They need assistance with (mark all that apply)

Tell us what you need assistance with or anything else that is of concern to you

When you complete and submit the form, you will see a confirmation page that reads

"Thank you for submitting your request to Elder Care Choices. Within one business day, an Aging Resource Specialist will contact you in the manner you requested."

If you do not see the confirmation page, please email ecc@seniorservicesinc.org, or call (336) 748-2171.