Request Care for a Loved One

Request Care for a Loved One

Complete this form to connect with trusted senior companions and respite caregivers through Localposh.
Section 1 — Contact Information

Tell us about yourself so we can reach you regarding care for your loved one.
Your Full Name*

First NameLast Name
Your Email Address*
example@example.com
Your Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
PhoneTextEmail
City*
State*
Zip Code*
SpouseAdult childFamily memberFriendCare managerOther
Section 2 — Loved One Information

Tell us about the person who will receive care.
Loved One's First Name*
Age of the person needing care*
Lives aloneLives with familyAssisted livingMemory care communityOther
City where care will take place*
Section 3 — Care Needs

Help us understand the type of care and support your loved one needs.
CompanionshipDementia / Alzheimer’s supportRespite care for a caregiverTransportation to appointmentsMeal preparationHelp around the homePost-hospital supportSafety supervisionOther
Dementia or Alzheimer’sCognitive declineFall riskMobility limitationsLoneliness or isolationPost-hospital recoveryOther
Fully mobileUses caneUses walkerWheelchairLimited mobility
YesNoSometimes
Section 4 — Scheduling Needs

Let us know your preferences for scheduling care.
4-hour visits8-hour visitsOvernight supportFlexible schedule
WeekdaysEveningsWeekendsFlexible
ImmediatelyWithin 1–2 weeksWithin a monthJust exploring options
Section 5 — Additional Details

Share anything else that would help us understand your loved one's needs.
Is there anything else you would like us to know about your loved one's needs?
Healthcare providerHospital or clinicGoogle searchFriend or familyCommunity organizationSocial mediaOther
Should be Empty:

Request Care for a Loved One

Section 1 — Contact Information

Section 2 — Loved One Information

Section 3 — Care Needs

Section 4 — Scheduling Needs

Section 5 — Additional Details