Tell us what you need

Who is the care for?

This tells us who we are talking to on the call.

My parent(s) My spouse Myself Someone else

The person receiving care

Full name *

Date of birth *

Street address *

Unit or apartment (optional)

City *

Postal code *

Phone number *

Include the area code.

The person filling in this form

If you are arranging care for yourself, enter your own details again.

Your name *

Your relationship to the person receiving care *

For example: daughter, son, spouse, or myself.

Your phone number *

Include the area code.

Your email *

Who to call in an emergency

Someone we can reach if the person receiving care cannot be reached.

Name *

Relationship to the person receiving care *

Phone number *

Include the area code.

What the caregiver needs to know

The minimum needed to send the right person on the first visit. Everything else is taken on the call, not typed here.

Getting around *

Walks unaided Uses a walker or cane Uses a wheelchair Mostly in bed

Are medication reminders needed *

Yes No

Allergies (optional)

Conditions the caregiver should know about (optional)

For example memory loss, diabetes or a recent fall. Short notes only.

Getting into the home

How will the caregiver get in? *

For example: door code, lockbox, or someone will be home.

Where can the caregiver park? *

For example: driveway, visitor spots, or street parking.

Language and anything else

Preferred language for communication *

Tell us the language you or your family member are most comfortable in. We record this preference and will talk it through with you on the call.

English Français (French)

Anything else we should know (optional)

Keep medical detail to the fields above. Our team will call you for the rest.

Who is the care for?

The person receiving care

The person filling in this form

Who to call in an emergency

The care you would like

What the caregiver needs to know

Getting into the home

Language and anything else