Senior Care Management Program Application
Welcome! I'm so happy that you decided to apply to my senior care management program. Having the right support while caring for a loved one makes all the difference in both their happiness and yours!

The more information you can provide, the better I will be able to understand your needs, so please be descriptive. This application will take about 10 minutes to complete and there is NO OBLIGATION to enroll in the program.

Please fill out the form below to apply and I will contact you within 24 hours with a response. You'll receive an e-mail from me with answers to your questions and if I think this program would be a good fit for your needs, you will also have the option to book a FREE 15-Minute Senior Care Consultation with me.

All information you submit is confidential and stored securely, according to my privacy policy.

Katherine Housh, RN, BSN
Chronic Wellness Nurse

Email address *
Name of person completing form *
Your answer
Phone number
Your answer
Name of senior requiring care
Your answer
What is your relationship with your senior?
Your answer
How are you currently paying for senior care needs? [Check all that apply.] *
How much are you willing to budget for senior care each month? *
How did you learn about senior care management?
Your answer
What is your biggest senior care concern or challenge right now?
Your answer
What is your biggest obstacle or roadblock to better senior care right now?
Your answer
Who are the primary caregivers right now? *
Your answer
If we were to work together, what would you hope to gain from the care management experience?
Your answer
Do you have any other questions or is there anything else that you would like to share?
Your answer
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms