CARELINK SOLUTIONS INC.
SERVICE REQUEST FORM Connecting people with compassionate, dependable support. Thank you for choosing CareLink Solutions. Please complete this form so we can better understand your support needs. A CareLink representative will contact you to discuss your request and next steps.
Applicant & Contact Information
Full Name
*
First Name
Middle Name
Last Name
Organization (if applicable)
Relationship
*
Self
Parent/Guardian
Family Member
Organization
Other
Relationship - Other (please specify)
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
City / Community
*
Support Request Details
Who Requires Support?
*
Child
Youth
Adult
Senior
Type of Support Requested
*
Community Support
Behaviour Support
Disability Support
Personal Support
Respite Care
Other
Type of Support Requested - Other (please specify)
Support Needed
*
One-Time
Casual
Weekly
Ongoing
Preferred Start Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Preferred Days
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Preferred Time
Morning
Afternoon
Evening
Overnight
Tell Us About Your Needs
*
Contact Preference, Consent, and Signature
Preferred Contact Method
*
Phone
Email
Text
Best Time to Contact
*
Morning
Afternoon
Evening
Consent to be contacted regarding this service request
*
I agree to be contacted regarding this service request by my preferred contact method.
Consent to understand service availability may vary
*
I understand that service availability may vary based on staffing, location, and program capacity.
Client Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
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