Should you wish to contact us,
please complete the form below.
Your Information
First Name
Last Name
Address
City
State
Zip Code
Daytime Telephone
Evening Telephone
Cellular Telephone
Email
Client Information
Your Relationship
to Client
Client Info
Client Name
Address
City
State
Zip Code
Daytime Telephone
Evening Telephone
Cellular Telephone
Email
Client Gender (Male/Female)
 M F
Client Age
Client Height
 FTIN
Client Weight
 LBS
Assistance Required
(as currently known)
Medications Administered Yes
No
Sometimes

explain:
Meal Preparation
 Yes
No
Sometimes

explain:
Dressing/Grooming
 Yes
No
Sometimes

explain:
Transportation to Doctors/Relatives/Friends
 Yes
No
Sometimes

explain:
Bathing or Showering
 Yes
No
Sometimes

explain:
Toilet, Incontinence
 Yes
No
Sometimes

explain:
Housekeeping, Laundry, etc.
 Yes
No
Sometimes

explain:
Do you have a pet? Yes
No

If yes...
How Many:

Cat
Dog
Bird

Others
Do you have indoor plants? Yes
No

Do they require care?
Yes
No
Current Living Situtation
 Lives at Home
Alone
Assisted Living Facility Hospital
Nursing Home,

explain:
Walking Ability
 Independent (Without Help),
With Cane
With Walker
Wheelchair/Beddridden explain:
Memory Loss
 No
Occasionally
Frequently,
Dementia diagnosis
Alzheimer diagnosis

explain:
Other Pertinent Medical Information?
Services Desired
Home Care, Live-Out, 4-6 Hrs Per Day
 6-8 Hrs Per Day,
 8-12 Hrs Per Day,
 24 Hrs Per Day,
Residential Care Facility, Assisted Living Facility
 Yes   No

explain:
Monthly Budget-Amount Range?
Timeframe Service Required
 Immediately
Within Weeks:
We are committed to your privacy and will not share your information with any third parties. Alternatively, you can call us with this information above at the telephone numbers listed below.

After the initial contact is made above of this on-line form, A.V. Home With Love and Care, Inc. staff will call you and/or your family, for a free in-home assessment to discuss the personal needs and wishes, which serve as a basis for your homecare personalized plan. This ensures that the caregiver can properly address your physical, social, emotional and financial needs.

Once all the involved parties can agree on the proposed initial fees and terms, we will then determine a customized care plan. After a caregiver has been assigned to your loved one, our managers will follow-up with personal, unannounced home visits and phone calls to ensure that the quality of care meets your expectations.