Request Care

Help us understand your situation and current needs. Then we’ll set up a free phone consultation so you can get the right support and care services to live well and age successfully at home.

Note: This form is fully customizable and seamlessly integrates with major CRMs, Google Docs, and more for automated data transfer. For your convenience, form fields are currently set as optional, allowing you to easily navigate through all steps without completing the form.
Optional features: Price calculation, payment collection, eSign, PDF Export, Recurring payment collections, etc.

Your Full Name

Email Address

What's the zip code of the person who needs care?

Who needs care or help at home?A loved oneMyselfA clientOther

Click on the best option for your current needs and we’ll ask for more details later.Memory Care At HomeSupport For Chronic ConditionsPost Hospitalization SupportEnd-of-life Care24/7 Complex CareCompanion CareLife Care PlanningHelp Around The HomeCompanion CareFrailty Or Fall-risk SupportAdults-with-disabilities Support

What is the care recipient’s first name?

What is the care recipient’s last name?

When do you need to start care?ImmediatelyIn the Coming WeeksPlanning for the FutureNot Sure

Do you know how much care you’ll need?A few hours a dayMost of the dayAround the clock supportNot sure

Are you planning for long-term care?No, just a few weeksYes, we need a long-term solutionNot sure

Can you give us more details on the care you’ll need?Personal Care (Help With Bathing, Grooming, Dressing, etc.)Supportive Care Within the Home (Meal Preparation, Companionship, etc)Lifestyle Support (Help With Planning and Scheduling Social Events and Activities)Transportation (Shopping, Errands, Medical Appointments, Social Events)Memory Care With a Diagnosis (Alzheimer's or Other Type of Dementia)Memory Care Without a Diagnosis (Confusion, Cognitive Decline, Memory Problems)Mobility Support (Help Getting Out of Bed, Going to the Bathroom, or Walking Safely With or Without a Walker)Total Body, Chairbound and Bedbound SupportCompanionship, Social Engagement, and Cognitive StimulationCoordination and oversight of overall wellnessSafety Observation or Wellness ChecksMedication Monitoring or ManagementNone/Other

CheckboxDo you need any additional services?Care management and oversight because family is far away or overwhelmedHelp navigating complex family dynamicsHealth advocacy with physicians, hospital, or insurance agencyCoordination of health, legal, or financial planningHouse management, help around the house, or coordinating repairsAssistance with finding and/or moving to an ideal home or communityNone/other

Have you had home care from a professional caregiver before?YesNo

Is the care recipient open to receiving care or resistant?OpenResistantNot sure

How are you planning to pay for care?Private pay/out-of pocketLong-term care insuranceMedicare/Medicaid/Medicare WaiverNot sure

What goals are you hoping to accomplish by setting up home care?

Consent *

Yes, I agree with the privacy policy and terms and conditions which I have read on this website. I agree Proud, care and its affiliates, subsidiaries, and/or agents may contact me via email, telephone, or text (Msg&data rates may apply. Recurring msgs. Text STOP to cancel) via automatic telephone dialing system and/or artificial or prerecorded voice, to arrange a free care consultation, as well as to provide me with general marketing communications. I understand I do not need to provide this consent to receive any good or service.

What happens next?

A dedicated Emerest representative will contact you within 24 hours.
We will discuss your needs.
We will select the best options for you based on your needs.

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