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Client Information:

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Phone Number*

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Care Services Needed:

What type of care are you interested in?*

Personal Care (help with bathing, dressing, grooming, etc.)

Companion Care (companionship, social activities, conversation)

Homemaking (light housekeeping, meal prep, running errands, etc.)

Respite Care (temporary relief for family caregivers)

Other

(Feel free to check all that apply. I’m here to help you find exactly what you need!)

Please describe your case*

Are there any special care needs or concerns you’d like us to know about?

Payment and Insurance Information:

How would you like to pay for home care services?

Private Pay (out-of-pocket)

Long-Term Care Insurance (if you have coverage)

Medicaid (for eligible services)

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Do you want assistance with Medicaid eligibility/enrollment:

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Care Schedule:

When do you need home care services to start?*

Immediately

Within the next 1-2 weeks

In a month or more

Is this a time-sensitive situation?*

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If yes, please tell me more so we can help prioritize your needs:*

Home care with Incare, a life choice made simple.

Phone: 212-202-0920
Fax: 718-646-3444
Email: Intake@incarehhc.com

Office Address:
1820 Gravesend Neck Road
Brooklyn, NY 11229

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Phone: 212-202-0920
Fax: 718-646-3444
Email: Intake@incarehhc.com
Office Address:
1820 Gravesend Neck Road
Brooklyn, NY 11229

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Home care with Incare, a life choice made simple.

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