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Your First Name:

Your Phone number

The person needing assistance is

Me

My Mom

My Dad

My Grandfather

My Grandmother

My Aunt

My Uncle

My Neighbor

My Friend/ Acquaintance

Husband/ Wife/ Partner

Other

First Name of person needing care

What tasks are becoming more difficult?

Your Email (if you have one)

Confirm that your phone and email are correct

Yes

Got it corrected!

How soon might you need care?

Gathering information at this time

In the next 24-48 hours

2-3 days from now

5-7 days from now

8-14 days from now

Next Month

Other important information about yourself and the assistance you are seeking.

Major cross streets or ZIP CODE

What are you most interested in/ or most need of? Check all that apply

Regular help in my home.

Someone to contact in Emergencies.

Someone to help manage and coordinate things.

This is all new to me, so I don't know what I need.

How did you hear about us?

Senior Fair

Read Article in Oro Valley Style Mag.

Google Search

Nextdoor

Pima Counsel on Aging Resource Guide

Heard Dr. Jan Speak at Senior Academy

Someone gave me your name/ card

We would like to thank the person who referred you...

IMPORTANT:

To protect your privacy, we ask only minimal questions on this form. We will ask more specific questions when we follow up via phone.

Also, if you do not hear back from us within 1 hour, please call 520-415-6363, as there could have been an issue with the message getting through. We don't want to miss an opportunity to provice excellent care to you or your loved one.

Thank you,

Bob and Jan

Opt-In:

By checking the opt-in box, I agree to receive SMS messages from A+ Elder Care Assistance (520-415-6363) on the phone number provided on the above form. Message frequency varies based on communication needs related to your inquiry, service updates, scheduling, and other important communication. Messaging and data rates may apply. You may opt out at any time by replying “STOP” to any message or HELP to get help. Mobile opt-in and information obtained as part of the SMS consent process or numbers for the purpose of SMS are not shared with any third parties or affiliates for marketing or any other purpose. We do not share your SMS consent with third parties or affiliates for their marketing purposes. Please note that text messaging is not entirely secure. See our Privacy Policy for details on how we handle your information."

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