AffordCare Home Care Intake Form

AffordCare Home Care Intake Form

Start Home Care in King & Pierce County. Answer a few quick questions so we can match you with the right support. For privacy, please do not include medical details here, we will confirm specifics by phone.
Which city or ZIP code will care be provided in?
We serve King & Pierce County
When would you like home care to start?
About how many hours per week?
We typically prefer 20+ hrs/week, but we can also support 10+ hrs/week if it’s consistent weekly.
What type of help/care is needed?

Memory Care -Dementia/AlzheimerPersonalized Care (bathing/dressing/toileting etc.)Companionship & SupervisionMeal Preparation/Nutrition SupportLight HousekeepingTransportation/ErrandsOvernight/24-7/Live-in CareOther
How would you like to proceed?

Call now (Mon–Fri 9am–5pm Pacific): 253-388-4901Request a callbackText me first
Full name

First NameLast Name
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred contact method

CallTextEmailOther
Best time window to reach you

9-11am11-1pm1-3pm3-5pmOther
For privacy, please do not include medical details here. For sensitive questions, call 253-388-4901 (Mon–Fri 9–5 PT; weekends by appointment).
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