Service Request

Name

Email Address

Phone number

Relationship to Person Needing Service Relationship to Person Needing Service Self Family Member Guardian Care Coordinator Other

Prefered Method of Contact Prefered Method of Contact Phone Email Either

Name of Person Needing Services

Age (Optional)

City/Town (Maine)

Does the individual currently live at home? Does the individual currently live at home? Yes No

Service(s) Requested Service(s) Requested Personal Care Services (non-medical) Respite Care Services Post-Hospital Support (non-medical) Not sure - I'd like help determining the right service

Type of Support Needed Type of Support Needed Bathing / personal hygiene Dressing / grooming Toileting / incontinence care Mobility / transfers Meal preparation Light housekeeping Companionship / supervision Support after hospital discharge Other

Preferred Days Preferred Days Weekdays Weekends Flexible

Preferred Time of Day Preferred Time of Day Morning Afternoon Evening Overnight

How soon are services needed? How soon are services needed? Immediately Within 1-2 weeks Within 30 days Just gathering information

How will services be paid? How will services be paid? Private Pay MaineCare Other Insurance Not sure / Need guidance

Additional Information

Consent & Submission Consent & Submission I understand that submitting this form does not guarantee services and that a representative from Excellent Care & Support will contact me to discuss availability and next steps.