Service Assessment Survey
How can we help?
Today's date
-
Month
-
Day
Year
Date
Primary customer
First Name
Last Name
Alternate contact
First Name
Last Name
Phone number
Alternate phone number
Email
example@example.com
Alternate Email
example@example.com
Customer mailing address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Customer service address (where work is to be performed
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Services that you require. Select all that apply
Declutter, downside, dispose
Yard cleaning & care
Pet care (feed, walk, bath, vet appt)
Transportation (medical & dental visits, post office, bank,etc)
Virtual appointments assist
Shopping & errands
Electronics & computer troubleshooting
Mail sorting, bill paying, assist with documents & correspondences
Lite house cleaning
Travel & event planning
Age-in-place solutions
Companionship (talk story, walks, puzzles, craft & hobbies, yarding, other activities)
Simple home fixes
How often do you require our service?
One time only
Once a week ______________
2-6 times per week (Mon, Tue, Wed, Thu, Fri, Sat, Sun)
Daily
What time range works best for you?
7am-9am
9am-11am
11am-1pm
1pm-3pm
3pm-5pm
5pm-7pm
Specific hours: Begin ____________ to ____________ End
How soon do you want to begin services
Immediately
Flexible
Any other activities or services that you wish we offered? Please list them :)
Any special instructions or additional information we should know
Other Comments:
Sign & date
Clear
Submit
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