Career Form – Together Care Health Services Inc.

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Relationship to Client

Are you completing this form for yourself or someone else?I am the clientFamily memberFriendHealthcare professionalOther

Text

If contacting on behalf of someone else:

Relationship to Client

Your Name

Client Information

Client Name

Client Age

GenderMaleFemaleOther

City where care is needed

Preferred Language for CommunicationEnglishFrenchOther

Do you require a caregiver who speaks this language?YESNOPreferred but not required

Services RequestedPersonal care (bathing, dressing, grooming)Mobility assistanceMeal preparationLight housekeepingCompanionshipMedication remindersDementia careRespite care for family caregiverPost-hospital recovery supportOther

Brief Description of Care Needs

Please briefly describe the care needs or support required.

Mobility StatusIndependentUses caneUses walkerUses wheelchairNeeds assistance walking

Cognitive ConcernsNoneMild memory concernsDementia / Alzheimer’sUnsure

Service Preferences

Preferred Start Date

Preferred DaysMondayTuesdayWednesdayThursdayFridaySaturdaySunday

Preferred TimeMorningAfternoonEveningOvernight

Estimated Hours per Visit

Urgency of Care

When are services needed?Immediately (within a few days)Within 1–2 weeksWithin the next monthJust exploring options

Contact Information

Phone Number

Email Address

Preferred Contact MethodPhone callText messageEmail

How Did You Hear About Us?Website searchReferralHealthcare providerFamily or friendSocial mediaOther

Privacy Notice

Your information will be kept confidential and used only to respond to your inquiry about home-care services. Together Care Health Services does not share personal information with third parties.

I consent to Together Care Health Services contacting me regarding my inquiry.

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admin@togethercarehealth.com

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Client Bill of Rights

Together Care Health Service

Contact us 24/7

admin@togethercarehealth.com

Social Media

Instagram Linkedin

Client Bill of Rights

Together Care Health Service

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