Free Care Consultation Complete the free no obligation assessment form & one of our team member will be in touch Free Care Consultation Personal InformationName *Email AddressPhone *Street AddressCityState/ProvinceZIP / Postal CodeDomiciliary Care Needs ChecklistAbout the Service UserAged 65 or olderHas a diagnosed disability or long-term conditionRecently discharged from hospitalLives alone and requires some assistanceRequires support due to dementia or memory issuesNeeds palliative or end-of-life careRequires companionship or social interactionIs a carer needing respite supportPersonal Care NeedsAssistance with washing or bathingHelp getting dressed or undressedSupport with grooming (hair, shaving, nail care)Help using the toilet or continence supportSupport with getting in and out of bedMedication reminders or administrationSupport with managing medical conditionsDaily Living SupportMeal preparation and planningHelp with eating or drinkingGrocery shopping or assistance with ordering foodLight housekeeping (laundry, cleaning, tidying)Support with managing bills and appointmentsEscorting to appointments or community activitiesEmotional & Social SupportCompanionship and conversationSupport to reduce loneliness or isolationEncouragement to maintain hobbies or interestsSupport with phone/video calls with familyMobility & SafetyAssistance moving around the homeHelp with walking aids or transfersFalls prevention measures or supervisionNight-time check-ins or overnight careSupport after a fall or injuryType of Care RequiredMorning visitsLunch-time visitsEvening visitsOvernight or sleep-in careLive-in careShort-term care (e.g. after hospital discharge)Long-term daily supportEmergency or urgent care needsLocation & PreferencesLocated within our service areaPreference for same-gender carerCultural/language/religious preferencesPets in the homeFamily involvement in care decisionsCare Start TimeImmediate startWithin the weekLong term planSubmit
