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 Name
Last Name
Your Email Address
*
example@example.com
Your Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Phone
Text
Email
City
*
State
*
Zip Code
*
Your relationship to the person needing care
*
Spouse
Adult child
Family member
Friend
Care manager
Other
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
*
Current living situation
*
Lives alone
Lives with family
Assisted living
Memory care community
Other
City where care will take place
*
Section 3 — Care Needs
Help us understand the type of care and support your loved one needs.
What type of support are you looking for? (Select all that apply)
*
Companionship
Dementia / Alzheimer’s support
Respite care for a caregiver
Transportation to appointments
Meal preparation
Help around the home
Post-hospital support
Safety supervision
Other
Primary health concerns (optional)
Dementia or Alzheimer’s
Cognitive decline
Fall risk
Mobility limitations
Loneliness or isolation
Post-hospital recovery
Other
Mobility level
*
Fully mobile
Uses cane
Uses walker
Wheelchair
Limited mobility
Does your loved one require supervision for safety?
*
Yes
No
Sometimes
Section 4 — Scheduling Needs
Let us know your preferences for scheduling care.
How many hours of care are you looking for?
*
4-hour visits
8-hour visits
Overnight support
Flexible schedule
Preferred schedule
*
Weekdays
Evenings
Weekends
Flexible
When would you like care to begin?
*
Immediately
Within 1–2 weeks
Within a month
Just 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?
How did you hear about Localposh?
*
Healthcare provider
Hospital or clinic
Google search
Friend or family
Community organization
Social media
Other
Submit
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