Request Home Care Services
Share your needs and contact details so our team can follow up with available non-medical care options.
Contact Information
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
Preferred Contact Method
Please Select
Phone
Text
Email
Best Time to Contact
Morning
Afternoon
Evening
Request Is For
Please Select
Myself
Parent
Spouse
Relative
Friend
Other
Care Recipient Information
Care Recipient Name
*
First Name
Middle Name
Last Name
Age of Care Recipient
City and ZIP Code Where Services Are Needed
*
Does the Care Recipient Live Alone?
*
Yes
No
Other
When Are Services Needed?
*
Please Select
Immediately
Within 1–2 Weeks
Within 30 Days
Just Exploring Options
Services Needed
What types of non-medical home care assistance are needed?
*
Personal care (bathing, dressing, grooming)
Companionship and social engagement
Meal preparation
Light housekeeping
Laundry and linen changes
Grocery shopping and errands
Transportation and appointment assistance
Medication reminders (no medication administration)
Mobility and transfer assistance
Respite care for family caregivers
Unsure — need help determining services
Other
Please specify other assistance needed
Care Schedule
How often is care needed?
*
Occasionally / as needed
1–2 days per week
3–4 days per week
5–7 days per week
Not sure yet
How many hours of care are needed per visit?
*
2–3 hours
4–5 hours
6–8 hours
8+ hours
Not sure yet
Preferred days of the week
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preferred time of day
Please Select
Morning
Afternoon
Evening
Overnight
Flexible
Not sure yet
Payment Information
Important: Due to the current pause affecting Indiana HCBS waiver provider enrollment, L.P.M.H. Home Care Services is currently accepting private-pay clients only. Medicaid waiver-funded services are not available through our agency at this time.
How do you anticipate paying for services?
*
Private pay / out of pocket
Long-term care insurance
Exploring payment options
Other
Acknowledgement
*
I acknowledge that the agency is currently accepting private-pay inquiries only.
Consent to Contact
Consent to Contact
*
I authorize L.P.M.H. Home Care Services to contact me regarding my inquiry using the contact information I provided. I understand that submitting this form does not guarantee service availability or establish a caregiver-client relationship.
SMS Consent
I agree to receive text messages from L.P.M.H. Home Care Services about my inquiry. Message and data rates may apply. Reply STOP to opt out.
Submit Care Inquiry
Should be Empty: