Program B · Client Intake

Client intake for homemaker & companion care.

Tell us who is reaching out, who would receive services, and the non-medical support you are looking for. It takes about 10–15 minutes. Your progress is saved on this device as you go, and you can get a secure link to finish on another phone, tablet, or computer.

This form is a request for information and service review. Submitting it does not guarantee service, enroll the client, create a service agreement, or authorize payment.

Service begins only after the request is reviewed, availability is confirmed, required documents are completed, payment is received, and a written service plan is approved.

561-208-1345Non-medical services · Boca Raton and Delray Beach only

Progress is saved on this device as you type.

About you

Fields marked REQUIRED NOW are needed to send this intake. Others can be completed before service begins.

Full name

Relationship to the prospective client

Phone number

Email address

Preferred contact method

Best time to contact

Are you the person who would receive services?

Are you the primary contact?

Are you an authorized representative (for example, power of attorney or guardian)?

Questions? Call Program B directly at 561-208-1345.