Refer Online

Would you like to refer someone?

If you would like to arrange care for yourself, your loved one, your patient or someone you know, please contact us using this online referral form. Carealot can arrange a free in-home assessment.

Name

Email Address

Address
Please include: State, Postcode, Address, Country

Phone (Work)

Phone (Home)

Fax

1. The person you are requesting this information for is:
Self
Spouse
Parent
Sister / Brother
Grandparent
Aunt / Uncle
Child
Friend
Other

2. Age:

3. When is care needed :
Immediately
2-3 weeks
4-6 weeks
1 year
Other

4. Support System :
Living with relatives / friends
Living close to relative / friends who check-in
Relatives / friends live out of town but visit
No relatives or friends

5. How mobile is this person:
No problems with mobility
Stumble from time to time
Fallen recently
Difficulty walking up stairs
Use cane or walker for security
Need help to get out of a chair
Not certain

6. Personal Care Needs (check all that apply ):
Do not have any personal care needs at this time
Needs assistance getting dressed and undressed
Needs assistance getting in and out of bathtub / washing hair / brushing hair / cleaning teeth / shaving, etc.
Needs assistance using the commode and / or incontinence management products
Not certain

7. Homemaking Needs (check all that apply ):
Shopping / buying groceries
Cleaning / laundry
Cooking meals
Running errands / escort to medical appointments
Companionship
Not certain

8. Health Problems (check all that apply):
Arthritis
Cancer
Stroke
Heart disease
Open wounds
Alzheimer"s or dementia
Pain
Parkinson"s disease
Diabetes
Brain injury
Lung problem
Recovering from surgery
None

9. Current level of assistance
Currently not receiving any assistance
Currently receiving some assistance from family / friends
Currently receiving support trough government agency
Receiving support through private insurance
Currently paying privately for assistance
Not certain