Request Home Care Services • Chicago and DuPage Counties Phone: 207-515-8850 • Email: makeawishhomecare@gmail.com
Client Full Name:
Date of Birth:
City:
Zip Code:
Primary Language:
Care Needed (check all that apply): Personal Care (bathing, dressing) Companion / Supervision Meal Prep Light Housekeeping Laundry Errands / Shopping Medication Reminders (non-medical) Transportation Other
Preferred Schedule: Select1-2 days per week3-5 days per weekWeekendsLive-inOvernights24/7
Estimated Weekly Hours: Select5-10 hours10-15 hours15-25 hours25-40 hoursLive-in / 24-7
Target Start Date:
Funding / Payer: SelectPrivate PayLong-Term Care InsuranceVA / VeteransIDoA CCP / HSPOther
Care Details / Notes:
Contact Name:
Relationship to Client:
Phone:
Email:
Best Time to Reach You: SelectAnytimeMorningAfternoonEvening
How did you hear about us? SelectFacebookInstagramGoogle SearchFriend or FamilyHospital / Discharge PlannerOther
I agree to be contacted by Make A Wish Home Care LLC about care services. This form is not a medical consent.
Submit Request Clear Form
Questions? Call 207-515-8850, Monday–Friday 10:00 AM–2:00 PM.
