Please take a moment to fill out all of the information below. Our Care Team takes a “mind-body-spirit-emotion-environment” approach to the practice of traditional medicine and care. Once we receive this application, one of our team members will contact you to learn some more about the person you are requesting care for. After we learn important information about regarding the health and wellbeing of your loved one – we schedule an in person Care Consultation.

Throughout our Care Assessment Process, we take the time to learn information about your past and present in order for us to help you plan for the future.

To learn more about our Care Consultations visit this link:

www.lifehousecares.org/apply/#Care-consultation

PRIMARY CONTACT INFORMATION


Relationship


PERSONAL INFORMATION FOR PERSON RECEIVING CARE


 Male Female Other


Age

Mobility



CARE NEEDS


Please tell us about your current living situation

Please select the services you are interested in:

 Care Home Medical Care Services Personal Care Services Workshops & Programs I am not sure Other

Other:


AVAILABILITY


Preferred Consultation Date

 MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY


Preferred Consultation Time

 MORNINGS AFTERNOONS EVENINGS