Mae's Grace | Get Care StartedMae's GraceAbout 2–3 minutesArizona non-medical home care intakeGet care startedShare the essentials so we can understand timing, support needs, and the best next step.Step 1 of 520% Leave this field blank Step 1About youThis helps us know who we should coordinate with first. Are you the best person for us to coordinate with right now? * Select oneYes — I'm the main contactNo — someone else decides Your connection to the client * Select oneI am the clientSpouse or partnerAdult child or family memberFriend or neighborGuardian or POAOther Your full name * Best phone number * Decision-maker name * Decision-maker phone Who should we contact first? * Select oneContact me firstContact the decision-maker firstEither is fine Step 2Where is care needed?We use this to confirm service area and understand the care setting. Choose the current setting * Select oneAt homeIndependent livingAssisted livingMemory careHospital discharge / returning homeNot sure yet Choose the current setting * At home Independent living Assisted living Memory care Hospital discharge / returning home Not sure yet City or ZIP where care is needed * Step 3When is support needed?This helps us gauge urgency and the kind of start plan that may fit best. How soon is help needed? * Select oneAs soon as possibleWithin 48 hoursThis weekWithin 2–4 weeksJust exploring options What schedule seems most likely? * Select oneA few hours a few days per weekDaily daytime supportEveningsOvernights24-hour coverageNot sure yet Step 4What help is needed?Select the support areas that matter most, then tell us the biggest concern right now.Support needs *Check all that apply. Companionship Personal care / ADL help Respite Overnight support 24-hour coverage After-hospital help Dementia support Transportation / errandsWhat is the biggest concern right now? * Safety at home Fall risk Memory changes / confusion Help with bathing, dressing, or toileting Caregiver burnout / family needs relief Returning home from hospital or rehab Not sure yetStep 5Review and submitYou can submit now, or add a few more details if you want us to have more context before we call or text. Add a few more details (optional) Helpful, but not required to get started. ⌄ Email address Best time to reach you How did you find us? Select oneGoogle searchFacebook / InstagramFriend or family referralHospital / discharge plannerSenior living communityWebsitePrinted material / flyerOther Is someone currently helping now? Select oneNo, not currentlyFamily is helpingA paid caregiver is helpingFacility staff is helpingSupport is inconsistent right now What time of day is hardest right now? Select oneMorningsAfternoonsEveningsOvernightVaries throughout the dayNot sure yet What would make this feel like a good solution? Select oneReliable help we can count onBetter safety and supervisionRelief for family caregiversHelp after hospital/rehabMore routine and structurePeace of mindOther Anything important we should know before we call or text?Examples: fall risk, dementia, recent hospitalization, two-person assist, pets in home, preferred contact time, or discharge date.EssentialsOptional details✓We received your intakeMae's Grace will follow up by call or text to talk through fit, timing, and the best starting plan for your family. Call/Text (623) 850-4011 Start over
