SCCS New Client Service Inquiry Form
Share your contact details, care needs, and schedule preferences so we can review your inquiry and reach out with next steps.
Person Completing Form
Full Name
*
First Name
Middle Name
Last Name
Relationship to Client
*
Please Select
Parent
Guardian
Spouse
Family Member
Friend
Case Manager
Healthcare Provider
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
*
Phone
Email
Prospective Client Information
Prospective Client Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Street Address
*
City
*
State
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Other
ZIP Code
*
Living Situation
*
Please Select
Lives alone
Lives with family
Lives with caregiver
Assisted living
Skilled nursing facility
Independent living
Other
Services Needed
Services Needed
*
Personal care/bathing/dressing/grooming
Companionship/sitter
Respite care
Mobility/transfers
Meal preparation
Light housekeeping
Medication reminders
Dementia/Alzheimer’s support
Hospice support
Transportation/appointment assistance
Safety/fall supervision
Feeding assistance
Other
If Other, please specify
Schedule Needs
Requested Start Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Days of Week Needed
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preferred Shift/Time Range
*
Please Select
Morning
Afternoon
Evening
Overnight
Flexible
Other
Estimated Hours Per Day
*
Overnight or Live-in Care Needed
*
No
Overnight Care
Live-in Care
Not Sure
Care Needs and Safety Information
Fall risk
Yes
No
Uses wheelchair, walker, or cane
Wheelchair
Walker
Cane
None
Other
Needs transfer assistance
Yes
No
Uses a Hoyer lift
Yes
No
Uses oxygen
Yes
No
Dementia or memory concerns
Yes
No
Behavioral concerns
Yes
No
Speech or communication difficulty
Yes
No
Needs toileting or incontinence assistance
Yes
No
Needs feeding assistance
Yes
No
Hospice or home health involved
Yes
No
Pets in the home
Yes
No
Other important conditions or equipment
Payment Information
Payment source
*
Private pay
Long-term care insurance
VA benefits
Medicaid/TennCare
Other
Note
Emergency / Primary Contact
Emergency / Primary Contact Name
*
First Name
Last Name
Relationship to the Client
*
Please Select
Spouse
Parent
Child
Sibling
Relative
Friend
Neighbor
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Care Request Details
Main reason care is needed and what assistance would be most helpful
*
Would you like to request an assessment or consultation?
*
Yes
No
Best day and time to contact you
*
Consent and Acknowledgments
Consent to be contacted by SCCS regarding this inquiry
*
I consent
Acknowledgment of inquiry-only status and no guarantee of service availability
*
I acknowledge
Electronic Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Inquiry
Submit Inquiry
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