Request Home Care Services Form

Complete this form to request home care services for yourself or someone else. It should take about 5–10 minutes. Our intake team will review your request and follow up promptly.

Full Name* This field is required.

First Name

Last Name

What is your relationship to the person needing services?* This field is required.

Your phone number* This field is required.

Please enter a valid phone number.

Email Address* This field is required.

example@example.com

What is the best way to contact you?* This field is required.

Phone call

Text message

What is the best time to contact you?

Morning

Afternoon

Evening

No preference

Full Name* This field is required.

First Name

Last Name

DOB

Date

Phone number (if different from yours)

Please enter a valid phone number.

Address Where Services Are Needed* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

County* This field is required.

Does the individual have a legal guardian or authorized representative?* This field is required.

Yes

Unsure

Guardian or Representative’s Name

First Name

Last Name

Guardian or Representative’s Phone Number

Please enter a valid phone number.

Guardian or Representative’s Email Address

example@example.com

Which services are you interested in?* This field is required.

Attendant Care

Homemaker Services

Structured Family Care

Transportation Services

Private-pay home care

Unsure and need guidance

Briefly describe the type of help needed* This field is required.

Examples may include personal care, bathing, dressing, mobility, toileting, meal preparation, housekeeping, laundry, errands, supervision, transportation, or family caregiving support.

What days are services needed?

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Flexible or unsure

What time of day is support needed?

Morning

Afternoon

Evening

Overnight

Flexible or unsure

Approximately how many hours of support are needed each week?

Less than 10 hours

10–20 hours

21–40 hours

More than 40 hours

Unsure

Already authorized

What is your preferred start date?

Date

Is the need urgent?

Yes

Please explain the urgency.

Shirley’s Angels Home Care is not an emergency response service. Call 911 for medical emergencies or immediate safety concerns.

How do you expect services to be paid for?* This field is required.

Indiana Medicaid waiver

Insurance

Private pay

Unsure

Other

What Medicaid plan or payer does the individual have?

Anthem

Humana

UnitedHealthcare

Indiana Medicaid

Other

Unsure

Not applicable

Is the individual currently approved for home and community-based services?

Yes

Application pending

Unsure

Has a service authorization already been issued?

Yes

Pending

Unsure

What services and weekly hours or units are authorized?

Does the individual have a case manager or care coordinator?

Yes

Unsure

Case Manager or Care Coordinator’s Name

First Name

Last Name

Phone number

Please enter a valid phone number.

Email address

example@example.com

Is the individual currently receiving home care services from another provider?

Yes

Unsure

Are you considering changing providers?

Yes

Possibly

Unsure

Is the individual currently in a hospital, rehabilitation facility, nursing facility, or other temporary setting?

Yes

Where are they currently located, and is there an expected discharge date?

Who currently provides most of the individual’s care?

Family member

Paid caregiver

Another agency

The individual manages independently

Other

These questions help with caregiver matching and prevent surprises.

Are there pets in the home?* This field is required.

Dog

Cat

Multiple pets

Other

Is smoking permitted inside the home?* This field is required.

Yes

Are there stairs in the home that the caregiver may need to use?* This field is required.

Yes

Unsure

Does the individual need transportation as part of the requested services?* This field is required.

Yes

Unsure

Are there any mobility or transfer needs we should know about?

Optional

Does the individual use mobility equipment?* This field is required.

Cane

Walker

Wheelchair

Hoyer lift

Hospital bed

Other

None

Other

Are there any communication, language, behavioral, or household considerations that may affect caregiver matching?

Optional. Please keep the wording neutral and do not include diagnoses.

Do you have any caregiver preferences?

Examples: preferred gender, language, smoking restrictions, comfort with pets, transportation ability, personality, or experience preferences.

Is there a specific caregiver you would like Shirley’s Angels Home Care to consider?* This field is required.

Yes

Caregiver’s Name

First Name

Last Name

Caregiver’s Contact Information

Is there anything else you would like our intake team to know?

All boxes must be checked to submit* This field is required.

I understand that submitting this form does not guarantee Medicaid eligibility, service authorization, caregiver availability, or an immediate start date.

I authorize Shirley’s Angels Home Care to contact me regarding this service request.

I authorize Shirley’s Angels Home Care to contact the case manager, care coordinator, guardian, or other professional listed in this form to discuss the service request.

Please use this secure form for client-specific information. Do not submit Social Security numbers, banking information, or emergency medical information.

Signature* This field is required.

Request Home Care Services Form