Tell us about your care needs.

This form helps us understand what your family is looking for. A team member will follow up — usually within one business day — to discuss next steps. Prefer to talk first? Call 980-495-2849.

A quick note: This form helps us understand your care needs. A team member will follow up to discuss next steps. For medical emergencies, call 911. Please share sensitive medical details over the phone or during intake — not in this form.

Thank you — your care request has been received.

A team member will reach out within one business day.

About you

Who is filling out this form?

Your full name*

Relationship to person needing care*

Your phone*

Your email*

About the client

The person who will receive care.

Client's full name*

Client's age

Client's home address

City

County*

Care needs

Tell us what kind of help is needed.

Type of care needed*

Days & times care is needed

Preferred start date

Insurance / payment information

Medical or mobility notes

Emergency contact

Emergency contact name

Emergency contact phone

Relationship

Anything else?

Additional message

I agree to be contacted by Home Care Connections NC about this care request. We will not share your information. See our Privacy Policy. *

Please do not include Social Security numbers, medical record numbers, or highly sensitive health information in this form. A team member will follow up to discuss care needs.

Submitting this form is the start of an intake conversation, not a guarantee of services. A team member will contact you to discuss eligibility, scheduling, and next steps. Coverage and eligibility may vary by plan.