Client Portal

📞 Your Contact Information

Person completing this form (family member, friend, or client)

First Name *

Last Name *

Relationship to Client *

Phone Number *

Email Address *

Best Time to Call

👤 Client Information

Person who will receive care

First Name *

Last Name *

Date of Birth

Age *

Home Address *

City *

ZIP Code *

Living Situation *

Phone Number

💝 Care Needs

Services Needed * (Select all that apply)

Companionship and conversation

Personal care (bathing, dressing, grooming)

Meal preparation and assistance

Medication reminders

Light housekeeping

Transportation and errands

Mobility assistance

Dementia/Alzheimer's care

Medical Conditions (if comfortable sharing)

Mobility Status *

Fully mobile/independent

Uses walker/cane

Wheelchair user

Needs assistance

Additional Care Information

📅 Schedule Preferences

When do you need care to start? *

Immediately (within 48 hours)

Within 1 week

Within 2 weeks

Within a month

Just planning ahead

Days of Week Needed *

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Preferred Time of Day *

Hours Per Day Needed *

💳 Insurance & Payment

Do you have Long-Term Care Insurance? *

Yes

No

Not sure

If yes, Insurance Company Name

Policy Number (if known)

Preferred Payment Method *

💳 Credit/Debit Card

📱 Zelle

💸 Venmo

💵 Cash App

📝 Check

💰 Cash

Payment Information:
• Credit/Debit Card: We accept Visa, Mastercard, American Express, Discover
• Zelle: [email protected]
• Venmo: @Anixicare
• Cash App: $Anixicare
• Check: Made payable to "Anixicare Services LLC"
• Cash: Accepted in person

About Pricing: We'll discuss exact pricing during your free consultation based on your specific needs. Our rates range from $38-45/hour depending on care level. We accept private pay, long-term care insurance, and VA benefits.

🚨 Emergency Contact

Person to contact in case of emergency (other than you)

Full Name

Relationship

Phone Number

Email

💬 How Did You Hear About Us?

Referral Source

Additional Comments or Questions