ÿþ<html> <head> <link rel=stylesheet href="seniorcare.css" type="text/css"> <title>SeniorCare Associates, Inc.</title> </head> <body bgcolor="#363154"> <table width="100%" align="center"> <tr> <td align="center"><img src="images/road.jpg" width="800" height="217"></td> </tr> <tr> </table> <table width="100%" align="center"> <tr> <td align="center"><a href="home.html"><img src="images/homeoff.jpg" width="125" border="0"></a> <a href="services.html"><img src="images/servicesoff.jpg" width="125" border="0"></a> <a href="resources.html"><img src="images/resourcesoff.jpg" width="125" border="0"></a> <a href="staff.html"><img src="images/staffoff.jpg" width="125" border="0"></a> <a href="getstarted.html"><img src="images/starton.jpg" width="125" border="0"></a> <a href="contact.html"><img src="images/contactoff.jpg" width="125" border="0"></a></td> </tr> </table> <table width="87%" align="center" cellpadding="15"> <tr> <td width="100%" bgcolor="#FDFD9D" valign="top"><BR> <P align="center"><font color="#312B5E" size="4"><b><u>Getting Started With Senior Care Associates</u></b></p> <p align="left">Senior Care Associates' care managers are available to answer your initial questions and help you start with services. Please fill in the form below to receive more information.</p> <b>Q: How do I initiate care management services?</b><br> <b>A:</b> A phone call to our office is the first step for a consultation with a care manager. The care manager will review your family situation and provide you an overview of our practice, and discuss how we may assist you.<br> <br> <b>Q: What geographical areas do you cover?</b><br> <b>A:</b> We provide services in the Northern Virginia area to include all of Arlington and Fairfax counties, and portions of Prince William and Loudoun Counties<br> <br> <b>Q: Are your geriatric care management services covered by Medicare or Long Term Care Insurance?</b><br> <b>A:</b> Medicare does not cover care management services. Long-term care insurance may provide coverage for some aspects of care management services. Consult your insurance company or review your plan to find out the details of coverage.<br> <br><b>Q: How are services billed?</b><br> <b>A:</b> Care management services are billed on a monthly basis. Care management fees are billed for the time spent providing support to the client and your family, travel time, phone calls, emails, correspondence, and costs incurred directly for the client such as purchases for medications and medical supplies.<br><br> <form id="emf-form" enctype="multipart/form-data" method="post" action="http://www.emailmeform.com/builder/form/7m0c6buxLnaXepSBd4w2"> <table style="text-align:left;" cellpadding="2" cellspacing="0" border="0" bgcolor="#FDFD9D"> <tr> <td style="" colspan="2"> <font face="Verdana" size="2" color="#312B5"><b style="font-size:20px;">Client Information</b><br /> <br /></font> </td> </tr> <tr valign="top"> <td id="td_element_label_0" style="" align="left"> <font face="Verdana" size="2" color="#312B5"><b>Name</b></font> </td> <td id="td_element_field_0" style=""> <input id="element_0" name="element_0" value="" size="30" class="validate[optional]" type="text" /> <div style="padding-bottom:8px;color:#000000;"></div> </td> </tr> <tr valign="top"> <td id="td_element_label_1" style="" align="left"> <font face="Verdana" size="2" color="#312B5"><b>Phone</b></font> </td> <td id="td_element_field_1" style=""> <table cellpadding='0' cellspacing='0' border='0'> <tr> <td style='padding-left:0px;'> <input maxlength='3' style='width:30px;' value='' id='element_1_1' name='element_1[]' type='text' class='validate[optional,custom[onlyNumber],length[3,3]]' /><br /> <font face="Verdana" size="2" color="#312B5">###</font> </td> <td style='padding-top:5px;padding-left:3px;' valign='top'> <font face="Verdana" size="2" color="#312B5">-</font> </td> <td style='padding-left:3px;'> <input maxlength='3' style='width:30px;' value='' id='element_1_2' name='element_1[]' type='text' class='validate[optional,custom[onlyNumber],length[3,3]]' /><br /> <font face="Verdana" size="2" color="#312B5">###</font> </td> <td style='padding-top:5px;padding-left:3px;' valign='top'> <font face="Verdana" size="2" color="#312B5">-</font> </td> <td style='padding-left:3px;'> <input maxlength='4' style='width:40px;' value='' id='element_1_3' name='element_1[]' type='text' class='validate[optional,custom[onlyNumber],length[4,4]]' /><br /> <font face="Verdana" size="2" color="#312B5">####</font> </td> </tr> </table> <div style="padding-bottom:8px;color:#000000;"></div> </td> </tr> <tr valign="top"> <td id="td_element_label_2" style="" align="left"> <font face="Verdana" size="2" color="#312B5"><b>Address</b></font> </td> <td id="td_element_field_2" style=""> <table cellpadding='0' cellspacing='0' border='0' width='100%'> <tr> <td colspan='2' style='padding-left:0;'> <input value='' type='text' style='width:99%;' id='element_2_1' name='element_2[]' class='validate[optional]' /><br /> <font face="Verdana" size="2" color="#312B5">Street Address</font> </td> </tr> <tr style=''> <td colspan='2' style='padding-left:0;'> <input value='' type='text' style='width:99%;' id='element_2_2' name='element_2[]' class='validate[optional]' /><br /> <font face="Verdana" size="2" color="#312B5">Address Line 2</font> </td> </tr> <tr> <td style='width:50%;padding-left:0;'> <input value='' type='text' style='width:99%;' id='element_2_3' name='element_2[]' class='validate[optional]' /><br /> <font face="Verdana" size="2" color="#312B5">City</font> </td> <td style='width:50%;padding-left:5px;'> <input value='' type='text' style='width:99%;' id='element_2_4' name='element_2[]' class='validate[optional]' /><br /> <font face="Verdana" size="2" color="#312B5">State / Province / Region</font> </td> </tr> <tr> <td style='width:50%;padding-left:0;'> <input value='' type='text' style='width:99%;' id='element_2_5' name='element_2[]' class='validate[optional]' /><br /> <font face="Verdana" size="2" color="#312B5">Postal / Zip Code</font> </td> <td style='width:50%;padding-left:5px;'> <select style='width:100%;' id='element_2_6' name='element_2[]' class='validate[optional]'> <optgroup label="North America"> <option value="Antigua and Barbuda"> Antigua and Barbuda </option> <option value="Aruba"> Aruba </option> <option value="Bahamas"> Bahamas </option> <option value="Barbados"> Barbados </option> <option value="Belize"> Belize </option> <option value="Canada"> Canada </option> <option value="Cook Islands"> Cook Islands </option> <option value="Costa Rica"> Costa Rica </option> <option value="Cuba"> Cuba </option> <option value="Dominica"> Dominica </option> <option value="Dominican Republic"> Dominican Republic </option> <option value="El Salvador"> El Salvador </option> <option value="Grenada"> Grenada </option> <option value="Guatemala"> Guatemala </option> <option value="Haiti"> Haiti </option> <option value="Honduras"> Honduras </option> <option value="Jamaica"> Jamaica </option> <option value="Mexico"> Mexico </option> <option value="Netherlands Antilles"> Netherlands Antilles </option> <option value="Nicaragua"> Nicaragua </option> <option value="Panama "> Panama </option> <option value="Puerto Rico "> Puerto Rico </option> <option value="Saint Kitts and Nevis"> Saint Kitts and Nevis </option> <option value="Saint Lucia"> Saint Lucia </option> <option value="Saint Vincent and the Grenadines"> Saint Vincent and the Grenadines </option> <option value="Trinidad and Tobago"> Trinidad and Tobago </option> <option value="United States" selected="selected"> United States </option> </optgroup> <optgroup label="South America"> <option value="Argentina"> Argentina </option> <option value="Bolivia"> Bolivia </option> <option value="Brazil"> Brazil </option> <option value="Chile"> Chile </option> <option value="Colombia"> Colombia </option> <option value="Ecuador"> Ecuador </option> <option value="Guyana"> Guyana </option> <option value="Paraguay"> Paraguay </option> <option value="Peru"> Peru </option> <option value="Suriname"> Suriname </option> <option value="Uruguay"> Uruguay </option> <option value="Venezuela"> Venezuela </option> </optgroup> <optgroup label="Europe"> <option value="Albania"> Albania </option> <option value="Andorra"> Andorra </option> <option value="Armenia"> Armenia </option> <option value="Austria"> Austria </option> <option value="Azerbaijan"> Azerbaijan </option> <option value="Belarus"> Belarus </option> <option value="Belgium"> Belgium </option> <option value="Bosnia and Herzegovina"> Bosnia and Herzegovina </option> <option value="Bulgaria"> Bulgaria </option> <option value="Croatia"> Croatia </option> <option value="Cyprus"> Cyprus </option> <option value="Czech Republic"> Czech Republic </option> <option value="Denmark"> Denmark </option> <option value="Estonia"> Estonia </option> <option value="Faroe Islands"> Faroe Islands </option> <option value="Finland"> Finland </option> <option value="France"> France </option> <option value="Georgia"> Georgia </option> <option value="Germany"> Germany </option> <option value="Greece"> Greece </option> <option value="Hungary"> Hungary </option> <option value="Iceland"> Iceland </option> <option value="Ireland"> Ireland </option> <option value="Italy"> Italy </option> <option value="Latvia"> Latvia </option> <option value="Liechtenstein"> Liechtenstein </option> <option value="Lithuania"> Lithuania </option> <option value="Luxembourg"> Luxembourg </option> <option value="Macedonia"> Macedonia </option> <option value="Malta"> Malta </option> <option value="Moldova"> Moldova </option> <option value="Monaco"> Monaco </option> <option value="Montenegro"> Montenegro </option> <option value="Netherlands"> Netherlands </option> <option value="Norway"> Norway </option> <option value="Poland"> Poland </option> <option value="Portugal"> Portugal </option> <option value="Romania"> Romania </option> <option value="San Marino"> San Marino </option> <option value="Serbia"> Serbia </option> <option value="Slovakia"> Slovakia </option> <option value="Slovenia"> Slovenia </option> <option value="Spain"> Spain </option> <option value="Sweden"> Sweden </option> <option value="Switzerland"> Switzerland </option> <option value="Ukraine"> Ukraine </option> <option value="United Kingdom"> United Kingdom </option> <option value="Vatican City"> Vatican City </option> </optgroup> <optgroup label="Asia"> <option value="ÿþAfghanistan"> ÿþAfghanistan </option> <option value="Bahrain"> Bahrain </option> <option value="Bangladesh"> Bangladesh </option> <option value="Bhutan"> Bhutan </option> <option value="Brunei Darussalam"> Brunei Darussalam </option> <option value="Myanmar"> Myanmar </option> <option value="Cambodia"> Cambodia </option> <option value="China"> China </option> <option value="East Timor"> East Timor </option> <option value="Hong Kong"> Hong Kong </option> <option value="India"> India </option> <option value="Indonesia"> Indonesia </option> <option value="Iran"> Iran </option> <option value="Iraq"> Iraq </option> <option value="Israel"> Israel </option> <option value="Japan"> Japan </option> <option value="Jordan"> Jordan </option> <option value="Kazakhstan"> Kazakhstan </option> <option value="North Korea"> North Korea </option> <option value="South Korea"> South Korea </option> <option value="Kuwait"> Kuwait </option> <option value="Kyrgyzstan"> Kyrgyzstan </option> <option value="Laos"> Laos </option> <option value="Lebanon"> Lebanon </option> <option value="Malaysia"> Malaysia </option> <option value="Maldives"> Maldives </option> <option value="Mongolia"> Mongolia </option> <option value="Nepal"> Nepal </option> <option value="Oman"> Oman </option> <option value="Pakistan"> Pakistan </option> <option value="Palestine"> Palestine </option> <option value="Philippines"> Philippines </option> <option value="Qatar"> Qatar </option> <option value="Russia"> Russia </option> <option value="Saudi Arabia"> Saudi Arabia </option> <option value="Singapore"> Singapore </option> <option value="Sri Lanka"> Sri Lanka </option> <option value="Syria"> Syria </option> <option value="Taiwan"> Taiwan </option> <option value="Tajikistan"> Tajikistan </option> <option value="Thailand"> Thailand </option> <option value="Turkey"> Turkey </option> <option value="Turkmenistan"> Turkmenistan </option> <option value="United Arab Emirates"> United Arab Emirates </option> <option value="Uzbekistan"> Uzbekistan </option> <option value="Vietnam"> Vietnam </option> <option value="Yemen"> Yemen </option> </optgroup> <optgroup label="Oceania"> <option value="Australia"> Australia </option> <option value="Fiji"> Fiji </option> <option value="Kiribati"> Kiribati </option> <option value="Marshall Islands"> Marshall Islands </option> <option value="Micronesia"> Micronesia </option> <option value="Nauru"> Nauru </option> <option value="New Zealand"> New Zealand </option> <option value="Palau"> Palau </option> <option value="Papua New Guinea"> Papua New Guinea </option> <option value="Samoa"> Samoa </option> <option value="Solomon Islands"> Solomon Islands </option> <option value="Tonga"> Tonga </option> <option value="Tuvalu"> Tuvalu </option> <option value="Vanuatu"> Vanuatu </option> </optgroup> <optgroup label="Africa"> <option value="Algeria"> Algeria </option> <option value="Angola"> Angola </option> <option value="Benin"> Benin </option> <option value="Botswana"> Botswana </option> <option value="Burkina Faso"> Burkina Faso </option> <option value="Burundi"> Burundi </option> <option value="Cameroon"> Cameroon </option> <option value="Cape Verde"> Cape Verde </option> <option value="Central African Republic"> Central African Republic </option> <option value="Chad"> Chad </option> <option value="Comoros"> Comoros </option> <option value="Democratic Republic of the Congo"> Democratic Republic of the Congo </option> <option value="Republic of the Congo"> Republic of the Congo </option> <option value="Djibouti"> Djibouti </option> <option value="Egypt"> Egypt </option> <option value="Equatorial Guinea"> Equatorial Guinea </option> <option value="Eritrea"> Eritrea </option> <option value="Ethiopia"> Ethiopia </option> <option value="Gabon"> Gabon </option> <option value="Gambia"> Gambia </option> <option value="Ghana"> Ghana </option> <option value="Gibraltar"> Gibraltar </option> <option value="Guinea"> Guinea </option> <option value="Guinea-Bissau"> Guinea-Bissau </option> <option value="Cote d'Ivoire"> Cote d'Ivoire </option> <option value="Kenya"> Kenya </option> <option value="Lesotho"> Lesotho </option> <option value="Liberia"> Liberia </option> <option value="Libya"> Libya </option> <option value="Madagascar"> Madagascar </option> <option value="Malawi"> Malawi </option> <option value="Mali"> Mali </option> <option value="Mauritania"> Mauritania </option> <option value="Mauritius"> Mauritius </option> <option value="Morocco"> Morocco </option> <option value="Mozambique"> Mozambique </option> <option value="Namibia"> Namibia </option> <option value="Niger"> Niger </option> <option value="Nigeria"> Nigeria </option> <option value="Rwanda"> Rwanda </option> <option value="Sao Tome and Principe"> Sao Tome and Principe </option> <option value="Senegal"> Senegal </option> <option value="Seychelles"> Seychelles </option> <option value="Sierra Leone"> Sierra Leone </option> <option value="Somalia"> Somalia </option> <option value="South Africa"> South Africa </option> <option value="Sudan"> Sudan </option> <option value="Swaziland"> Swaziland </option> <option value="United Republic of Tanzania"> United Republic of Tanzania </option> <option value="Togo"> Togo </option> <option value="Tunisia"> Tunisia </option> <option value="Uganda"> Uganda </option> <option value="Zambia"> Zambia </option> <option value="Zimbabwe"> Zimbabwe </option> </optgroup> </select><br /> <font face="Verdana" size="2" color="#312B5">Country</font> </td> </tr> </table> <div style="padding-bottom:8px;color:#000000;"></div> </td> </tr> <tr valign="top"> <td id="td_element_label_3" style="" align="left"> <font face="Verdana" size="2" color="#312B5"><b>Medical History</b></font> </td> <td id="td_element_field_3" style=""> <textarea id="element_3" name="element_3" cols="45" rows="5" class="validate[optional]"> </textarea> <div style="padding-bottom:8px;color:#000000;"></div> </td> </tr> <tr valign="top"> <td id="td_element_label_4" style="" align="left"> <font face="Verdana" size="2" color="#312B5"><b>Age</b></font> </td> <td id="td_element_field_4" style=""> <input id="element_4" name="element_4" class="validate[optional,custom[onlyNumber]]" value="" size="5" type="text" /> <div style="padding-bottom:8px;color:#000000;"></div> </td> </tr> <tr valign="top"> <td id="td_element_label_5" style="" align="left"> <font face="Verdana" size="2" color="#312B5"><b>Client Needs/ Concerns:</b></font> </td> <td id="td_element_field_5" style=""> <textarea id="element_5" name="element_5" cols="45" rows="10" class="validate[optional]"> </textarea> <div style="padding-bottom:8px;color:#000000;"></div> </td> </tr> <tr valign="top"> <td id="td_element_label_6" style="" align="left"> <font face="Verdana" size="2" color="#312B5"><b>Is Client currently receiving any services?</b></font> </td> <td id="td_element_field_6" style=""> <textarea id="element_6" name="element_6" cols="45" rows="10" class="validate[optional]"> </textarea> <div style="padding-bottom:8px;color:#000000;"></div> </td> </tr> <tr valign="top"> <td colspan="2" style=""> <h3 style="font-size:14px;padding:10px 0 6px 0;border-top:1px dotted #CCCCCC;margin:14px 0;position:static;" id="element_7" name="element_7"> <font face="Verdana" size="2" color="#312B5">Your Information</font> </h3> <div style="padding-bottom:8px;color:#000000;"></div> </td> </tr> <tr valign="top"> <td id="td_element_label_8" style="" align="left"> <font face="Verdana" size="2" color="#312B5"><b>Name</b></font> </td> <td id="td_element_field_8" style=""> <input id="element_8" name="element_8" value="" size="30" class="validate[optional]" type="text" /> <div style="padding-bottom:8px;color:#000000;"></div> </td> </tr> <tr valign="top"> <td id="td_element_label_9" style="" align="left"> <font face="Verdana" size="2" color="#312B5"><b>Email</b></font> </td> <td id="td_element_field_9" style=""> <input id="element_9" name="element_9" class="validate[optional,custom[email]]" value="" size="30" type="text" /> <div style="padding-bottom:8px;color:#000000;"></div> </td> </tr> <tr valign="top"> <td id="td_element_label_10" style="" align="left"> <font face="Verdana" size="2" color="#312B5"><b>Phone</b></font> </td> <td id="td_element_field_10" style=""> <table cellpadding='0' cellspacing='0' border='0'> <tr> <td style='padding-left:0px;'> <input maxlength='3' style='width:30px;' value='' id='element_10_1' name='element_10[]' type='text' class='validate[optional,custom[onlyNumber],length[3,3]]' /><br /> <font face="Verdana" size="2" color="#312B5">###</font> </td> <td style='padding-top:5px;padding-left:3px;' valign='top'> <font face="Verdana" size="2" color="#312B5">-</font> </td> <td style='padding-left:3px;'> <input maxlength='3' style='width:30px;' value='' id='element_10_2' name='element_10[]' type='text' class='validate[optional,custom[onlyNumber],length[3,3]]' /><br /> <font face="Verdana" size="2" color="#312B5">###</font> </td> <td style='padding-top:5px;padding-left:3px;' valign='top'> <font face="Verdana" size="2" color="#312B5">-</font> </td> <td style='padding-left:3px;'> <input maxlength='4' style='width:40px;' value='' id='element_10_3' name='element_10[]' type='text' class='validate[optional,custom[onlyNumber],length[4,4]]' /><br /> <font face="Verdana" size="2" color="#312B5">####</font> </td> </tr> </table> <div style="padding-bottom:8px;color:#000000;"></div> </td> </tr> <tr valign="top"> <td id="td_element_label_11" style="" align="left"> <font face="Verdana" size="2" color="#312B5"><b>Address</b></font> </td> <td id="td_element_field_11" style=""> <table cellpadding='0' cellspacing='0' border='0' width='100%'> <tr> <td colspan='2' style='padding-left:0;'> <input value='' type='text' style='width:99%;' id='element_11_1' name='element_11[]' class='validate[optional]' /><br /> <font face="Verdana" size="2" color="#312B5">Street Address</font> </td> </tr> <tr style=''> <td colspan='2' style='padding-left:0;'> <input value='' type='text' style='width:99%;' id='element_11_2' name='element_11[]' class='validate[optional]' /><br /> <font face="Verdana" size="2" color="#312B5">Address Line 2</font> </td> </tr> <tr> <td style='width:50%;padding-left:0;'> <input value='' type='text' style='width:99%;' id='element_11_3' name='element_11[]' class='validate[optional]' /><br /> <font face="Verdana" size="2" color="#312B5">City</font> </td> <td style='width:50%;padding-left:5px;'> <input value='' type='text' style='width:99%;' id='element_11_4' name='element_11[]' class='validate[optional]' /><br /> <font face="Verdana" size="2" color="#312B5">State / Province / Region</font> </td> </tr> <tr> <td style='width:50%;padding-left:0;'> <input value='' type='text' style='width:99%;' id='element_11_5' name='element_11[]' class='validate[optional]' /><br /> <font face="Verdana" size="2" color="#312B5">Postal / Zip Code</font> </td> <td style='width:50%;padding-left:5px;'> <select style='width:100%;' id='element_11_6' name='element_11[]' class='validate[optional]'> <optgroup label="North America"> <option value="Antigua and Barbuda"> Antigua and Barbuda </option> <option value="Aruba"> Aruba </option> <option value="Bahamas"> Bahamas </option> <option value="Barbados"> Barbados </option> <option value="Belize"> Belize </option> <option value="Canada"> Canada </option> <option value="Cook Islands"> Cook Islands </option> <option value="Costa Rica"> Costa Rica </option> <option value="Cuba"> Cuba </option> <option value="Dominica"> Dominica </option> <option value="Dominican Republic"> Dominican Republic </option> <option value="El Salvador"> El Salvador </option> <option value="Grenada"> Grenada </option> <option value="Guatemala"> Guatemala </option> <option value="Haiti"> Haiti </option> <option value="Honduras"> Honduras </option> <option value="Jamaica"> Jamaica </option> <option value="Mexico"> Mexico </option> <option value="Netherlands Antilles"> Netherlands Antilles </option> <option value="Nicaragua"> Nicaragua </option> <option value="Panama "> Panama </option> <option value="Puerto Rico "> Puerto Rico </option> <option value="Saint Kitts and Nevis"> Saint Kitts and Nevis </option> <option value="Saint Lucia"> Saint Lucia </option> <option value="Saint Vincent and the Grenadines"> Saint Vincent and the Grenadines </option> <option value="Trinidad and Tobago"> Trinidad and Tobago </option> <option value="United States" selected="selected"> United States </option> </optgroup> <optgroup label="South America"> <option value="Argentina"> Argentina </option> <option value="Bolivia"> Bolivia </option> <option value="Brazil"> Brazil </option> <option value="Chile"> Chile </option> <option value="Colombia"> Colombia </option> <option value="Ecuador"> Ecuador </option> <option value="Guyana"> Guyana </option> <option value="Paraguay"> Paraguay </option> <option value="Peru"> Peru </option> <option value="Suriname"> Suriname </option> <option value="Uruguay"> Uruguay </option> <option value="Venezuela"> Venezuela </option> </optgroup> <optgroup label="Europe"> <option value="Albania"> Albania </option> <option value="Andorra"> Andorra </option> <option value="Armenia"> Armenia </option> <option value="Austria"> Austria </option> <option value="Azerbaijan"> Azerbaijan </option> <option value="Belarus"> Belarus </option> <option value="Belgium"> Belgium </option> <option value="Bosnia and Herzegovina"> Bosnia and Herzegovina </option> <option value="Bulgaria"> Bulgaria </option> <option value="Croatia"> Croatia </option> <option value="Cyprus"> Cyprus </option> <option value="Czech Republic"> Czech Republic </option> <option value="Denmark"> Denmark </option> <option value="Estonia"> Estonia </option> <option value="Faroe Islands"> Faroe Islands </option> <option value="Finland"> Finland </option> <option value="France"> France </option> <option value="Georgia"> Georgia </option> <option value="Germany"> Germany </option> <option value="Greece"> Greece </option> <option value="Hungary"> Hungary </option> <option value="Iceland"> Iceland </option> <option value="Ireland"> Ireland </option> <option value="Italy"> Italy </option> <option value="Latvia"> Latvia </option> <option value="Liechtenstein"> Liechtenstein </option> <option value="Lithuania"> Lithuania </option> <option value="Luxembourg"> Luxembourg </option> <option value="Macedonia"> Macedonia </option> <option value="Malta"> Malta </option> <option value="Moldova"> Moldova </option> <option value="Monaco"> Monaco </option> <option value="Montenegro"> Montenegro </option> <option value="Netherlands"> Netherlands </option> <option value="Norway"> Norway </option> <option value="Poland"> Poland </option> <option value="Portugal"> Portugal </option> <option value="Romania"> Romania </option> <option value="San Marino"> San Marino </option> <option value="Serbia"> Serbia </option> <option value="Slovakia"> Slovakia </option> <option value="Slovenia"> Slovenia </option> <option value="Spain"> Spain </option> <option value="Sweden"> Sweden </option> <option value="Switzerland"> Switzerland </option> <option value="Ukraine"> Ukraine </option> <option value="United Kingdom"> United Kingdom </option> <option value="Vatican City"> Vatican City </option> </optgroup> <optgroup label="Asia"> <option value="ÿþAfghanistan"> ÿþAfghanistan </option> <option value="Bahrain"> Bahrain </option> <option value="Bangladesh"> Bangladesh </option> <option value="Bhutan"> Bhutan </option> <option value="Brunei Darussalam"> Brunei Darussalam </option> <option value="Myanmar"> Myanmar </option> <option value="Cambodia"> Cambodia </option> <option value="China"> China </option> <option value="East Timor"> East Timor </option> <option value="Hong Kong"> Hong Kong </option> <option value="India"> India </option> <option value="Indonesia"> Indonesia </option> <option value="Iran"> Iran </option> <option value="Iraq"> Iraq </option> <option value="Israel"> Israel </option> <option value="Japan"> Japan </option> <option value="Jordan"> Jordan </option> <option value="Kazakhstan"> Kazakhstan </option> <option value="North Korea"> North Korea </option> <option value="South Korea"> South Korea </option> <option value="Kuwait"> Kuwait </option> <option value="Kyrgyzstan"> Kyrgyzstan </option> <option value="Laos"> Laos </option> <option value="Lebanon"> Lebanon </option> <option value="Malaysia"> Malaysia </option> <option value="Maldives"> Maldives </option> <option value="Mongolia"> Mongolia </option> <option value="Nepal"> Nepal </option> <option value="Oman"> Oman </option> <option value="Pakistan"> Pakistan </option> <option value="Palestine"> Palestine </option> <option value="Philippines"> Philippines </option> <option value="Qatar"> Qatar </option> <option value="Russia"> Russia </option> <option value="Saudi Arabia"> Saudi Arabia </option> <option value="Singapore"> Singapore </option> <option value="Sri Lanka"> Sri Lanka </option> <option value="Syria"> Syria </option> <option value="Taiwan"> Taiwan </option> <option value="Tajikistan"> Tajikistan </option> <option value="Thailand"> Thailand </option> <option value="Turkey"> Turkey </option> <option value="Turkmenistan"> Turkmenistan </option> <option value="United Arab Emirates"> United Arab Emirates </option> <option value="Uzbekistan"> Uzbekistan </option> <option value="Vietnam"> Vietnam </option> <option value="Yemen"> Yemen </option> </optgroup> <optgroup label="Oceania"> <option value="Australia"> Australia </option> <option value="Fiji"> Fiji </option> <option value="Kiribati"> Kiribati </option> <option value="Marshall Islands"> Marshall Islands </option> <option value="Micronesia"> Micronesia </option> <option value="Nauru"> Nauru </option> <option value="New Zealand"> New Zealand </option> <option value="Palau"> Palau </option> <option value="Papua New Guinea"> Papua New Guinea </option> <option value="Samoa"> Samoa </option> <option value="Solomon Islands"> Solomon Islands </option> <option value="Tonga"> Tonga </option> <option value="Tuvalu"> Tuvalu </option> <option value="Vanuatu"> Vanuatu </option> </optgroup> <optgroup label="Africa"> <option value="Algeria"> Algeria </option> <option value="Angola"> Angola </option> <option value="Benin"> Benin </option> <option value="Botswana"> Botswana </option> <option value="Burkina Faso"> Burkina Faso </option> <option value="Burundi"> Burundi </option> <option value="Cameroon"> Cameroon </option> <option value="Cape Verde"> Cape Verde </option> <option value="Central African Republic"> Central African Republic </option> <option value="Chad"> Chad </option> <option value="Comoros"> Comoros </option> <option value="Democratic Republic of the Congo"> Democratic Republic of the Congo </option> <option value="Republic of the Congo"> Republic of the Congo </option> <option value="Djibouti"> Djibouti </option> <option value="Egypt"> Egypt </option> <option value="Equatorial Guinea"> Equatorial Guinea </option> <option value="Eritrea"> Eritrea </option> <option value="Ethiopia"> Ethiopia </option> <option value="Gabon"> Gabon </option> <option value="Gambia"> Gambia </option> <option value="Ghana"> Ghana </option> <option value="Gibraltar"> Gibraltar </option> <option value="Guinea"> Guinea </option> <option value="Guinea-Bissau"> Guinea-Bissau </option> <option value="Cote d'Ivoire"> Cote d'Ivoire </option> <option value="Kenya"> Kenya </option> <option value="Lesotho"> Lesotho </option> <option value="Liberia"> Liberia </option> <option value="Libya"> Libya </option> <option value="Madagascar"> Madagascar </option> <option value="Malawi"> Malawi </option> <option value="Mali"> Mali </option> <option value="Mauritania"> Mauritania </option> <option value="Mauritius"> Mauritius </option> <option value="Morocco"> Morocco </option> <option value="Mozambique"> Mozambique </option> <option value="Namibia"> Namibia </option> <option value="Niger"> Niger </option> <option value="Nigeria"> Nigeria </option> <option value="Rwanda"> Rwanda </option> <option value="Sao Tome and Principe"> Sao Tome and Principe </option> <option value="Senegal"> Senegal </option> <option value="Seychelles"> Seychelles </option> <option value="Sierra Leone"> Sierra Leone </option> <option value="Somalia"> Somalia </option> <option value="South Africa"> South Africa </option> <option value="Sudan"> Sudan </option> <option value="Swaziland"> Swaziland </option> <option value="United Republic of Tanzania"> United Republic of Tanzania </option> <option value="Togo"> Togo </option> <option value="Tunisia"> Tunisia </option> <option value="Uganda"> Uganda </option> <option value="Zambia"> Zambia </option> <option value="Zimbabwe"> Zimbabwe </option> </optgroup> </select><br /> <font face="Verdana" size="2" color="#312B5">Country</font> </td> </tr> </table> <div style="padding-bottom:8px;color:#000000;"></div> </td> </tr> <tr valign="top"> <td id="td_element_label_12" style="" align="left"> <font face="Verdana" size="2" color="#312B5"><b>What is your relationship to client?</b></font> </td> <td id="td_element_field_12" style=""> <input id="element_12" name="element_12" value="" size="45" class="validate[optional]" type="text" /> <div style="padding-bottom:8px;color:#000000;"></div> </td> </tr> <tr valign="top"> <td id="td_element_label_13" style="" align="left"> <font face="Verdana" size="2" color="#312B5"><b>How did you learn about Senior Care Associates?</b></font> </td> <td id="td_element_field_13" style=""> <input id="element_13" name="element_13" value="" size="45" class="validate[optional]" type="text" /> <div style="padding-bottom:8px;color:#000000;"></div> </td> </tr> <tr> <td colspan="2" align="center"> <input name="element_counts" value="14" type="hidden" /> <input name="embed" value="forms" type="hidden" /><input value="Submit" type="submit" /> </td> </tr> </table> </form> </tr> <tr> <td colspan="2" bgcolor="#FDFD9D" valign="top" align="center"><font color="#312B5E" size="3">Senior Care Associates, Inc.&nbsp;&nbsp;&nbsp;5510 Hamlet Hill Court&nbsp;&nbsp;&nbsp;Fairfax, VA 22030<br>Office: (703) 502-0240&nbsp;&nbsp;&nbsp;Fax: (703) 502-8927&nbsp;&nbsp;&nbsp;<a href="mailto:linda@seniorcare-associates.com">linda@seniorcare-associates.com</a></td> </tr> <tr> <td colspan="2" bgcolor="#FDFD9D" valign="top" align="center"><font color="#312B5E" size="2">Senior Care Associates provides geriatric care management services in northern Virginia including the cities of Alexandria, Annandale, Arlington, Ashburn, Burke, Centreville, Chantilly, Clifton, Fairfax, Falls Church, Great Falls, Herndon, McLean, Manassas, Manassas Park, Oakton, Potomac Falls, Reston, Springfield, Sterling, Tysons Corner, Vienna and Woodbridge. These cities are in the counties of Arlington, Fairfax, Loudoun and Prince William.</td> </tr> <tr> <td colspan="2" bgcolor="#FDFD9D" valign="top" align="center"><font color="#312B5E" size="1">&#169; 2012 SeniorCare Associates, Inc., All Rights Reserved<BR>Site designed by <a href="http://www.jewelcode.com">JewelCode Corporation</a></td> </tr> </table> </body> </html>