Vermont Long-Term Care Ombudsman Intake Form

Information you submit below will go to the Vermont Long-Term Care Ombudsman Program. You do not have to give us your name or contact information.

If you would like us to respond to you, you must include a phone number or an email address. If you would prefer to leave a message for us on our helpline, you can call 1-800-889-2047 and select Option 3.

You must fill in the fields that are marked with *

Your first name

Your last name

Your phone number

You must provide a phone number if you want us to call you.

Your email address

You must provide an email address if you want us to email you.

Why are you contacting the Long-Term Care Ombudsman Program?

I have questions or concerns about my own long-term care.

I have questions or concerns about someone else's long-term care.

How do you normally receive long-term care?

In a nursing home, assisted living facility or residential care home.

At home or in an adult care home through Choices for Care Medicaid program (Long-Term Care Medicaid).

At home or in an adult care home through private pay or from an unpaid caregiver.

At home through a government benefit program that is not Chices for Care Medicaid

I do not have long-term care right now.

How does that person normally receive long-term care?

In a nursing home, assisted living facility or residential care home.

At home or in an adult care home through Choices for Care Medicaid program (Long-Term Care Medicaid).

At home or in an adult care home through private pay or from an unpaid caregiver.

At home through a government benefit program that is not Chices for Care Medicaid

They do not have long-term care right now.

What is the name of the long-term care facility?

What is the room number?

The town / city where you live

The state where you live

The town / city where that person lives

The state where that person lives

Please describe the question or issue you would like the Long-Term Care Ombudsman Program to help you with.

What is the best way to reach you?

Examples: Phone, text, email, long-term care facility's main phone number, etc.

When you click Submit

When you click Submit, your message will be sent to the Vermont Long-Term Care Ombudsman Program at Vermont Legal Aid. We will reply within three business days.