• Get Started

  • Which of the following best describes you?*

  • Individual Form

    Individual Information

  • Do you have a Legally Authorized Representative?*
  • Format: (000) 000-0000.
  • Will this person be providing services for you?
  • Format: (000) 000-0000.

  • Guardian Form

    Guardian and Loved One Information

  • Format: (000) 000-0000.
  • Will you be providing services yourself?
  • Are you your loved one's Legally Authorized Representative?*
  • Format: (000) 000-0000.

  • Case Manager Form

    Your Information

  • Format: (000) 000-0000.

  • Case Manager Form

    Participant and Guardian Information

  • Does your client have a Legally Authorized Representative?*
  • Format: (000) 000-0000.
  • Will this person be providing services?
  • Format: (000) 000-0000.

  • Individual Form

    Case Manager Information

  • Guardian Form

    Case Manager Information

  • Format: (000) 000-0000.

  • Individual Form

    Staff Information

  • Guardian Form

    Staff Information

  • Case Manager Form

    Staff Information

  • Who would you like to provide your services?

  • We’ve added you as a prospective caregiver. Employment is subject to Simpl Care’s hiring requirements, including background checks and training.
  • We’ve added your guardian as a prospective caregiver. Employment is subject to Simpl Care’s hiring requirements, including background checks and training.
  • We’ve added their guardian as a prospective caregiver. Employment is subject to Simpl Care’s hiring requirements, including background checks and training.

  • Staff member 1

  • Format: (000) 000-0000.
  • ✓ {st1_name} · {st1_phone}

  • Staff member 2 (backup)

  • Format: (000) 000-0000.
  • ✓ {st2_name} · {st2_phone}
  • This person is already on your list. Please edit this staff member or remove the duplicate.

  • Staff member 3

  • Format: (000) 000-0000.
  • ✓ {st3_name} · {st3_phone}
  • This person is already on your list. Please edit this staff member or remove the duplicate.

  • Staff member 4

  • Format: (000) 000-0000.
  • ✓ {st4_name} · {st4_phone}
  • This person is already on your list. Please edit this staff member or remove the duplicate.

  • Staff member 5

  • Format: (000) 000-0000.
  • ✓ {st5_name} · {st5_phone}
  • This person is already on your list. Please edit this staff member or remove the duplicate.

  • Staff member 6

  • Format: (000) 000-0000.
  • ✓ {st6_name} · {st6_phone}
  • This person is already on your list. Please edit this staff member or remove the duplicate.

  • Staff member 7

  • Format: (000) 000-0000.
  • ✓ {st7_name} · {st7_phone}
  • This person is already on your list. Please edit this staff member or remove the duplicate.

  • Staff member 8

  • Format: (000) 000-0000.
  • ✓ {st8_name} · {st8_phone}
  • This person is already on your list. Please edit this staff member or remove the duplicate.

  • Simpl Care recommends at least two trained staff so your services can continue if your main staff person is sick, on vacation, or leaves. If you choose one staff person for now, I understand that:

    • There may be times when Simpl Care does not have a trained staff person available for my services.
    • Simpl Care will work with me and my case manager on a backup plan, which will be written into my person-centered plan.
    • I can add staff at any time by contacting Simpl Care.
    • This choice does not affect my eligibility, and I am free to choose any provider agency.

  • Individual Form

    Service Information

  • Guardian Form

    Service Information

  • Case Manager Form

    Service Information

  • What Services do you need?
  • What Services do you need?
  • What Services do you need?
  • Should be Empty: