Non-medical services only. We do not provide hands-on personal care, medication administration, nursing, lifting, or transfers.

Your Name *

Relationship to the person receiving services *

Phone *

Email *

Preferred contact method

CallTextEmail

Name of person receiving services

Service address (Palm Beach County)

Living situation

Requested hours per week

Standard recurring plans require at least 25 hours per week.

Requested service days per week

Minimum 3 service days per week.

Preferred start date

Does the person receiving services need any of the following? (We do not provide these services.)

Scope acknowledgment (required if any item above is selected)

I understand these services are outside this provider's authorized scope and will not be provided

Supporting documents (optional)

Optional: care notes, schedules, POA or guardianship paperwork, or a service letter. Max 25MB per file.

Emergency contact (name)

Emergency contact phone

Tell us what would help most at home

Acknowledgment *

I understand this provider offers non-medical homemaker and companion services onlyI understand no hands-on personal care, medication administration, nursing, lifting, or transfers are providedI understand service begins only after review, confirmed availability, completed documents, payment, and an approved written service planI consent to be contacted by phone, text, or email

Request homemaker & companion services.

Homemaker & Companion Services Request