Who Are We Assisting Today?
Kindly share your contact details and role so our care coordination team can reach out personally to discuss your family’s needs.
Loved One or Authorized Representative?
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Client
Family Member
Caregiver
Other
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Full Name
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First Name
Last Name
Email Address
*
example@example.com
Preferred Method of Contact
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Phone
Email
Text Message
Relationship to Client
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Your Loved One’s Care Profile
Please tell us a little about the person who will be receiving care. This helps us personalize our approach and ensure every detail is handled with dignity and attention.
Full Name
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First Name
Last Name
Client Age Range
Please Select
0–12
13–17
18–64
65+
Living Situation
Please Select
Alone
With Family
Assisted Living
Nursing Home
Other
County / Location of Care
Personalized Care Services
Kindly choose the services that best reflect your family’s goals for comfort, independence, and peace of mind. Our team will create a personalized plan from your selections.
Please select the services you’re interested in.
Companion & Personal Care – Everyday support focused on safety, dignity, and comfort. Includes conversation, light housekeeping, meal preparation, grooming, mobility support, and medication reminders. (Typical rate range: $25–$32/hr)
Family Care Coordination – Professional oversight for families: appointment scheduling, progress updates, and communication with physicians and care teams. (Typical rate: $75–$100 per visit or $250/month)
Digital Wellness & Technology Support – Assistance with video calls, telehealth setup, device support, and online safety. (Plans from $40–$140/month)
Transportation & Errand Support – Safe accompaniment to appointments, pharmacy runs, and essential errands.
Respite Care for Family – Temporary coverage that gives family caregivers peace of mind and a chance to recharge.
Other (please specify)
Personalized Care Insights
Based on your earlier responses, we’d love to gather a few more details to help us design the most thoughtful and effective care experience.
What are your primary goals of care?
Improve Mobility
Enhance Emotional Wellness
Companionship
Medication Support
Personal Hygiene
Other
Which areas of emotional or comfort support would be most beneficial?
Companionship
Stress Relief
Calming Presence
Mindfulness Activities
Other
How often would you like digital wellness sessions?
Weekly
Biweekly
Monthly
Approximately how many hours of care per week are you anticipating?
What personality traits or styles would you prefer in your caregiver or companion?
Gentle and Patient
Friendly and Talkative
Quiet and Observant
Energetic and Engaging
Experienced with Seniors
Flexible and Adaptable
Other
Which activities or hobbies best describe your loved one’s interests?
Reading
Gardening
Music
Art
Cooking
Traveling
Watching TV or Movies
Other
Scheduling & Start Date
Let us know your preferred timing so we can coordinate availability and match you with the right caregiver.
When would you like services to begin?
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Month
-
Day
Year
Date
What type of schedule best fits your care needs?
Days
Evenings
Overnights
Weekends
As Needed
Do you need immediate coverage or are you planning for a future start date?
Immediate Coverage
Future Planning
Will you require assistance verifying or processing insurance coverage?
Yes
No
Additional Information & Supporting Documents
If there’s anything else we should be aware of, please include it below. You can also upload discharge notes, care plans, or physician instructions to help us prepare for your consultation.
Please share any details, preferences, or notes that will help us better understand your situation.
Upload any relevant documents (hospital discharge papers, mobility notes, or physician instructions).
Upload a File
Drag and drop files here
Choose a file
Cancel
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Premium Enhancements (Optional)
Kindly Companions also offers concierge-level support designed to reduce stress for families and enhance quality of life at home
Would you like to add extended companion hours for added presence and peace of mind?
Yes, include extended companion hours
Not at this time
Would you like transportation support for appointments and errands?
Yes, include transportation concierge service
Not at this time
Confirmation & Next Steps
Please review and submit your form. A member of our coordination team will personally follow up to confirm details, answer any questions, and begin building your care plan.
Would you like to add wellness-focused visits for emotional balance and overall well-being?
Yes, include specialized wellness support
Not at this time
Your privacy is protected. All submissions are reviewed exclusively by our care coordination team.
Preferred Consultation Timing
Please Select
Within 24 hours
Within 3 days
Within a week
Not urgent
I confirm the information provided is accurate to the best of my knowledge.
*
I confirm the information provided is accurate to the best of my knowledge.
Submit My Request
Submit My Request
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