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Comfort Keepers Racine, WI

1131 Prairie Dr #100
Racine, Wisconsin 53406
(262) 884-3930

Take Our Home Care Survey

Name: Comfort Keepers Home Care
Address: 1131 Prairie Dr #100, Racine, Wisconsin, 53406
Telephone: (262) 884-3930

It may be time for you to consider in-home care for your loved one! Start by taking our short Home Care Survey to help you better understand whether the time may have come to pursue care options for your loved one.

The simple form below has four questions and will take about a minute to complete.

About Your Loved One

Choose the following statements that apply to your loved one:

Does your loved one wear dirty clothing or the same outfit day after day?

Is it apparent your loved one is not showering or bathing?

Is your loved one losing weight?

Are there signs of confusion such as not knowing the date, where he/she is, or the season of the year?

Do the refrigerator or cupboards contain outdated food; or lack nutritious food?

Is the home cluttered or have mail, newspapers, bills accumulated?

Are you finding expired medications or medications that are not being taken?

ZIP Code where care is needed

About Yourself

Your first name

Your last name

Your email address

Your telephone number

Is this a cell phone number?

Anything else you would like to tell us?