Private Pay Care Inquiry Form
Share your care needs and schedule so we can estimate costs and confirm next steps.
Contact Information
Your Full Name
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Relationship to Person Needing Care
*
Please Select
Self
Spouse
Parent
Child
Other family member
Friend/representative
Other
Person Needing Care
Client Name
*
First Name
Last Name
Age
*
City / ZIP Code
*
Where will care be provided?
*
Please Select
Private residence
Independent living
Assisted living
Other
Type of Assistance Needed
Type of assistance needed
*
Bathing / personal hygiene
Dressing / grooming
Toileting / incontinence assistance
Mobility assistance
Transfers
Meal preparation
Light housekeeping
Laundry
Medication reminders
Companionship
Transportation / errands
Dementia / memory care support
Respite care
Post-hospitalization assistance
Other
Does the client require skilled nursing or other medical services?
*
No
Yes
Unsure
Schedule Needed
How many days per week is care needed?
*
3 days
4 days
5 days
6 days
7 days
Approximately how many hours per visit are needed?
*
4 hours
5–6 hours
7–8 hours
9–12 hours
More than 12 hours
24-hour / around-the-clock care
Preferred days of the week
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preferred time of day
*
Morning
Afternoon
Evening
Overnight
Flexible
When should services begin?
*
Please Select
Immediately / within 48 hours
Within 1 week
Within 2 weeks
Within 30 days
Planning for future care
Financial Qualification
Are you prepared to privately pay for the requested services?
*
Yes
Yes, but I would like to discuss service options
I need assistance understanding payment options
No
Who will be financially responsible for services?
*
Please Select
Client
Spouse
Adult child/family member
Trust/estate
Long-term care insurance
Other
Does the client have long-term care insurance?
Yes
No
Unsure
Client Condition / Care Complexity
Does the client live alone?
*
Yes
No
Unsure
Is the client able to walk independently?
*
Yes
No
With assistance
Unsure
Does the client require transfer assistance?
*
Yes
No
Unsure
Is the client currently hospitalized or in rehabilitation?
*
Hospitalized
In rehabilitation
Neither
Unsure
Does the client have dementia or significant memory impairment?
*
Yes
No
Unsure
Has the client experienced a recent fall?
*
Yes
No
Unsure
Are there pets in the home?
Yes
No
Unsure
Is anyone currently providing care?
*
Yes
No
Unsure
Briefly describe the primary reason for seeking care
*
Decision-Making
Who will make the final decision about care?
*
I will
Client
Spouse
Adult child/family member
Multiple family members
Legal guardian / POA
Other
Are the primary decision-makers aware that you are requesting information from Madea?
*
Yes
No
I am the primary decision-make
Next Step
What would you like to happen next?
*
Schedule a phone consultation
Schedule an in-home assessment
Have someone call me to discuss options
I'm only gathering information right now
By submitting this form, I understand that the pricing shown is an estimate based upon the information provided and does not constitute a final service agreement or guaranteed rate. Final services, scheduling, caregiver availability, and pricing are subject to Madea's assessment and service agreement.
*
Submit
Should be Empty: