Gifted Care Intake

Start here

Let's get your loved one set up with care

Four short steps, about 3 minutes. First — which sounds right for you?

Insurance-funded

Their doctor writes an order for skilled nursing and/or a home aide; coverage depends on their plan.

Private-pay

Starts at $40/hr, 4-hour daily minimum, 3 days/week minimum, licensed CNAs — no doctor's order needed, care can start faster.

Not sure yet

No problem — we'll call and help you decide.

Their Full Name*

Date of Birth*

Best Contact Number*

Home Address

Do they have Medicare or Medicaid?

Medicare

Medicaid

Not sure

Quick one

Their doctor's info

Needed so we can request the order for insurance-funded care.

Physician's Name

Office Phone Number

Is their doctor aware they're seeking home care?

Yes

No

Not sure

What they need

Care needs & schedule

Check what applies — you can always adjust this later.

Other

Days & hours needed

Desired Start Date

Almost done

A quick health snapshot

A few sentences is plenty — we'll go deeper together during their care assessment.

Their health, mobility & vision

Allergies & current medications

Anything else that helps us match the right caregiver?

Last step

Review & send

Here's everything you entered. You can still go back and edit anything.

I certify this information is accurate, and I authorize Gifted Care Agency to contact the physician and/or insurance provider listed to verify eligibility and coordinate care.

Your Name*

Your Relationship to Them*

Let's get your loved one set up with care

Their doctor's info

Care needs & schedule

A quick health snapshot

Review & send

Thank you!