Companion Care Interest Form

This survey gathers information from individuals interested in companion care services. Your feedback helps us understand your needs and preferences.

Fields marked with * are required.

Name *

Your name or the person you're filling this out for

Relationship to the person requiring companion care

e.g. self, spouse, child, friend

Contact information *

Email address or phone number

Age of the person requiring companion care *

Gender *

Marital status *

Married

Single

It's complicated

Have you heard of companion care services before? *

Yes

Would you be interested in learning more about companion care services? *

Definitely interested

Somewhat interested

Not interested at this time

Does the person requiring care currently receive assistance with daily activities? *

Yes, regularly

Yes, occasionally

No, not at all

Which companion care services would you be most interested in? *

Select all that apply

Companionship and conversation

Meal preparation and planning

Assistance with errands and transportation

Light housekeeping and organizing

Medication reminders

Assistance with hobbies or activities

Other (please specify)

How often would these services be needed? *

Daily

Several times a week

Once a week

Occasionally, as needed

Preferred times or days for companion care

Any additional questions or comments about companion care services?