• Metro Care Connect – Care Placement Intake Form

    Home care referral intake form. Please complete all required fields and provide any details that help with care placement.

  • Client Information

  •  -

  • Care Recipient Details

  • Gender
  • Type(s) of care needed*

  • Schedule & Availability

  • When are you looking to start care?*
  • Preferred start date
     - -
  • Days needed*
  • Time needed*

  • Health & Condition Details

  • Does the client have dementia or memory issues?*

  • Home Environment

  • Pets in the home?*
  • Smoking in the home?*
  • Stairs in the home?*
  • Parking available?*

  • Caregiver Preferences

  • Preferred gender*
  • Prefer non-smoker caregiver?*
  • Must have own transportation?*

  • Placement Readiness

  • Are you actively looking to start care?*
  • Have you worked with a private caregiver before?*
  • Preferred arrangement*

  • Payment Method & Insurance (for matching purposes)

  • How do you plan to pay for care?*
  • Is your policy currently active?
  • Does your policy allow hiring private caregivers?
  • Are you currently approved for the program?
  • Do you have a fiscal intermediary or agency set up?
  • Should be Empty: