For Short-Term Care Pay-as-you-go, Care Club Membership, Long-Term Care, and Background Check services fill out the application below on this page.  We will follow up with you shortly.Taking the time to fully understand our client’s needs is what makes our placement process so successful. Before you begin working with us we ask that you fill out the application below. It details all of the specific requests you may have for your family’s specific situation and will help us make a placement or help us help you make a decision that is an appropriate choice. We are dedicated to making sure that you are completely happy with the process and the end result.The form below is not only a needs assessment, it specifies what you can expect from us as a client and is a contract defining our terms of service. We look forward to being an extension of your family and helping to make your life easier. Please call our office any time if you need additional assistance or simply would rather discuss by telephone at 877-553-4231, ext. 1.

You will be prompted to fill out billing information after this form is completed on the submission page. To complete the process you must fill out our secure billing collection form.

Client Form

Short-Term Care Pay-as-you-go, Annual Care Club Membership, Long-Term Care, and Due Diligence Services Application
    Regarding options for Back Up and Short Term Care: We offer Short Term Referral Services where we simply charge a referral fee and the Client Family pays the Care Provider directly OR the ability for Crunch Care to act as the employer for a flat hourly rate where we pay the Care Provider. Please select which model you would like to utilize. Long Term Referral Placement Services: For cases 6 months or longer with a set schedule. Referral fee by percentage applies. Client is the employer. Due Diligence: Background Check services.
  • Schedule and Assessment

    Please be as descriptive as possible when filling out the hours of care you will need. Specify if you will need a.m., p.m., or 24 hour shifts.
  • Please print and retain all of our agreements as listed at the top of this page.
  • Fees for full employment services will be based on the original booking confirmation. Should the hours be extended they will be audited in our weekly billing based off time card review and will automatically charged to your billing credit card.
  • **Please print and retain a copy of your completed Client Application for your records.**
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