Outreach Client Inquiry Form

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Please answer the following questions below. Add any additional information/questions you may have on question 9.

1. Who is this inquiry for? *

Myself

Parent

Spouse/Partner

Other Family Member

Friend/Neighbor

2. What is the client’s age range? *

Under 40

40–59

60–74

75–84

85+

3. What types of services are you most interested in? (Select all that apply) *

Comprehensive Nursing Assessments – In-person/virtual health & safety evaluation, customized care plan.

Care Coordination & Case Management – Communication between providers, scheduling, follow-up care.

Medication Management & Safety – Review prescriptions, identify risks, caregiver education.

Chronic Disease Management – Ongoing support for diabetes, COPD, dementia, hypertension, etc.

Hospital-to-Home Transition Care – Post-discharge support, safety checks, medication review.

Patient & Family Advocacy – Healthcare navigation, advance care planning, insurance/Medicare/Medicaid help.

Wellness & Preventive Care – Nutrition, exercise, fall prevention, health promotion.

Ongoing Monitoring & Reassessments – Regular RN check-ins, updated plans, 24/7 support options.

Required

4. What are your current concerns or goals? (Select all that apply) *

Preventing ER visits or hospital readmissions

Reducing caregiver strain

Medication safety and education

Fall prevention and home safety

Better communication with doctors/providers

Managing one or more chronic conditions

Planning for long-term care needs

General health & wellness support

Required

5. When would you like services to begin? *

Immediately (within 1–2 weeks)

Soon (within 1 month)

Planning ahead (1–3 months)

Not sure yet – just exploring options

6. What type of visits do you prefer? *

In-Person

Virtual (Telehealth)

Combination of Both

Not sure yet

7. Where is the client located? *

Milwaukee Area

Madison Area

Green Bay Area

La Crosse Area

Other Wisconsin Location: ____________________

8. How would you like us to contact you? *

Phone Call

Text Message

Please enter contact information (phone number, email address) *

9. Do you have any additional notes or questions?

Submit

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