Are you enquiring for yourself or on behalf of someone else? * MyselfSomeone else
How many people require care? * SinglePerson Couple
Are they, or the person currently being cared for? * YesNo
What kind of care is required? * Personal CareLive in CareRespitePalliative CareHouse KeepingOther
How many days per week is care required? * 1 day2-3 days4-5 days7 daysOther
What days and time of the week do you require care? * Monday-FridayMornings Monday-FridayAfternoon Monday-FridayEvenings WeekendsMornings WeekdaysAfternoon WeekendsEvenings Overnight 24 hoursOther
How long will each visit last? * 45 minutes to 1 hour2 – 3 hours4 – 6 hoursLonger than 6 hoursOther
Which of the following do you need care with? MedicationPersonal careHousekeepingAttending social activitiesCookingShoppingTransportOther
How mobile is the person needing care? * Fully mobileWalks with a frame/stickNeeds a wheelchair to move aroundConfined to bed
Which of the following medical or care needs does the client have? NoneAlzheimersArthritisDementiaDiabetesPalliative careParkinsonsPhysical therapyOther
When would you like the care to begin? * As soon as possibleWithin the next 2 weeksWithin the next monthWithin the next 3 monthsOther
Name *
Email *
Telephone *
Post code *
Address *
How would the care be paid for? * PrivatelyLocal Authority Direct PaymentNHSOther
I have read and understood the terms and conditions *
