Do you prefer phone, text or email communication? Please Specify
What type of support are you looking for (e.g., daily, weekly, occasional)? Answer Here
How did you hear about My Helping Companion? Answer Here
Do you prefer to meet in person or virtually? Please Select In-Person Virtually
Who will be attending the meeting with you? Please Select Self Family Friend Life Partner Daughter Son Other
Are there specific days and times when you need assistance? If so, please specify... Answer Here
Do you require help with appointment scheduling? Please Select Yes No
Do you need assistance with cooking and meal preparation? Please Select Yes No
Do you have any allergies we should know about? Please Specify
Do you have any health conditions that you would like us to know about? Please Specify
Do you need help with household cleaning tasks? Please Specify
Do you enjoy walking and exercising? If yes, what kind of activities do you enjoy? Please Specify
What are some of your hobbies? Please Specify
Are there any pets in your home that we need to consider? Please Specify
What is your budget for services? Please Specify
Do you need assistance with budgeting or managing your finances? Please Select Yes No
Do you need assistance with computers, phones or other technology? Please Select Yes No
Do you need assistance with advocating for yourself? Please Select Yes No
Are you currently employed or are you retired or unable to work? Please Select Employed Full Time Employed Part Time Retired Unable to Work
Do you need assistance with job searching or career development? Please specify Answer Here
Do you need help with any planning or organizing of events? Please Select Yes No
Do you need help establish yourself with a doctor? Please Select Yes No
Do you need help with repairs or other maintenance around your home? Please Specify
Do you need someone to go to appointments with you? Please Select Yes No
Is there anything else you would like us to know? (We will elaborate on this more during our meeting). Please Specify
Do you require assistance with medication reminders? Please Select Yes No
How many people in your household need support and what are their ages? Please Specify