New Client Consultation Form

Consent to be Contacted by the Media

Share your story about home care and hospice. We are gathering stories to respond to media requests about the workforce shortage impacting your ability to access critical home care services. By sharing your story here, we invite you to talk about your struggles to find services or staff, the hardships you are facing as providers and direct care workers, and success stories that highlight the value of health care at home.
Patient / Parent/Guardian / Provider Name *

First Name Last Name
Email *
example@example.com
Location: City *
City
Location: Zip Code *
Postal/Zip Code
Phone Number *
Please enter a valid phone number.
Choose your Service *

Star Plus Private Duty Nursing
Star Plus: Weekly Authorized direct service worker/Attendant Hours: *
Star Plus: Weekly Hours UNSTAFFED *
Current Situation (Star Plus) (select all that apply) *

Suffering access to care issues related to Nursing Shortage in home care Suffering access to care issues related to direct service worker (AKA attendant / home health aide /nurse aid) shortage in home care Patient was hospitalized related to negative outcome from unstaffed direct service worker hours. Patient was unable to return home after a hospital stay because there is no access to care related to direct service worker shortage Other
PDN: Weekly Authorized direct service worker/Attendant Hours: *
PDN: Weekly Hours UNSTAFFED *
Current Situation (PDN) (select all that apply) *

Suffering access to care issues related to nursing shortage in home care Child is hospitalized related to negative outcome from unstaffed nursing hours related to the nursing shortage in home care Child is hospitalized but cannot go home because there is no access to care related to nursing shortage in home care Child has suffered a negative outcome from unstaffed nursing hours related to the nursing shortage in home care Other
Are you comfortable with video interview? *

Yes No
Are you comfortable with phone interview? *

Yes No
What day of the week is best for a potential interview? *

Monday Tuesday Wednesday Thursday Friday Saturday Sunday
What time of day are best for a potential interview? *

Morning Afternoon Evening
Have you participated in media interviews in the past *

Yes No Other
Signature *

Clear
Should be Empty:

Consent to be Contacted by the Media