Gold Friends At Home Request Form

Gold Friends at Home Information Request Form

After we receive your information request, we'll be in touch soon!
Your Name*

First NameLast Name
Your Email Address
example@example.com
Your Phone Number*
Please enter a valid phone number.
May we text you regarding this inquiry at the phone number you provided?*

YesNo
Who are you requesting companionship for?*

MyselfMy Parent or Other RelativeSomeone Else
What is the ZIP Code of the address where you would like to schedule a visit?*
Only ZIP Codes that are in our service area are listed here. Please email goldfriendsathome@yahoo.com with questions.
Please provide the complete address where you would like to schedule a visit. (Not ready to share the address? No problem! Feel free to skip this section.)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Select the companion services that interest you. (Select all that apply.)

Preserving memories (e.g., scrapbooking, photo albums, journaling)Card & letter writingNutrition guidance/meal companionGames & puzzles (e.g., movies, TV, board games, jigsaw puzzles, word games)ReadingOther
How long of a visit would you like to schedule?

1 hour2 hours3 hours4 hoursI don't know--let's discuss!Other
What is your scheduling preference?

Weekdays onlyWeekends onlyBoth during the week and on weekendsI'm flexible--either during the week or on weekendsI don't know--let's discuss!
Are you seeking a one-time companion visit or multiple visits?

Just one visitPossibly more than one visitI don't know--let's discuss!
List any questions or provide details you'd like to share with us.
Please acknowledge our scope of services disclaimer.*

I understand that Gold Friends at Home does not provide medical care, housekeeping, or help with bathing or personal hygiene.
Please acknowledge this scheduling and payment policy.*

I understand that submitting this form does not guarantee an appointment. A representative from Gold Friends at Home will contact me to discuss rates and confirm scheduling. I am under no obligation to book services. If I choose to proceed, I understand that payment is required in advance to secure the appointment. If services are not provided due to fault of Gold Friends at Home, a full refund will be issued. Otherwise, payments are non-refundable but may be applied to a rescheduled appointment. Refunds may be considered in compassionate circumstances at the sole discretion of Gold Friends at Home.
Please email goldfriendsathome@yahoo.com if you have questions or trouble completing this form. Thank you!
How did you hear about us?*

Online searchFacebookReferralOther
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Gold Friends at Home Information Request Form