APPLY FOR CARE
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 *
YOUR FIRST NAME *
Your answer
YOUR LAST NAME *
Your answer
YOUR EMAIL *
Your answer
YOUR PHONE NUMBER *
Your answer
PERSONAL INFORMATION FOR PERSON RECEIVING CARE
FIRST NAME *
Your answer
LAST NAME *
Your answer
GENDER *
WHAT COMMUNITY DO YOU CURRENTLY LIVE IN? *
Your answer
ARE YOU CURRENTLY RECEIVING CARE SERVICES? *
Your answer
AGE *
MOBILITY *
Required
CARE NEEDS
PLEASE SPECIFY YOUR CURRENT SITUATION *
PLEASE SELECT THE SERVICES YOU ARE INTERESTED IN: *
Required
Please let us know your CARE WISH LIST (Let us know the support you are hoping for) *
Your answer
AVAILABILITY
PREFERED CONSULTATION DATE *
Required
PREFERRED CONSULTATION TIME *
Required
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