Client Consultation Form 

Thank you for considering us to care for you or your loved one. Please complete the form below so we can better understand your care needs and how we can best support you.

Whether you're seeking companionship, personal care, respite care, transportation, meal preparation, or assistance with daily living activities, our compassionate team is here to provide personalized, high-quality care with dignity and respect.

🌿 Limited-Time Welcome Offer: The first 3 new private-pay clients who enroll in services will receive 5% off their care plan.

Once your inquiry is received, we'll contact you within one business day to discuss your needs, answer your questions, and schedule your complimentary consultation.

We look forward to helping your loved one bloom with compassionate care.

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Name *
Address (City, State, and Zip) *
Age *
Phone number *
E-mail *
Preferred contact method *
Required
What type of care is needed? (check all that apply) *
Required
Estimated Hours of Care Needed  -  Ethereal Gardens Home Care has a two-hour minimum per visit. *
Required
How many days per week will care be needed?   *
Preferred days and times   *
When do you need care to start? *
MM
/
DD
/
YYYY
How urgent is this?  (Immediate / Within 1–2 weeks / Planning ahead) *
Is there a legal Guardian? If yes move to next section. *
Required
Provide Name, Relationship and Contact Information of Guardian. 
Are you or your loved one currently in
How will your care services be paid for?   *
Required
Do you currently have a Long-Term Care Insurance policy?   *
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