Senior Care request Form
Thank you so much for contacting Best American Home Care. We will contact you both by email and by phone shortly!
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BAHC Senior Care Request Form
Your name (For us to contact you)
Best Phone Number
Email address
Confirm email address
State
County
City and Zip code
Briefly describe the specific type of care needed
At this time, we only accept private pay. Can you afford private pay?
Yes
No
Age of Senior
60-70
71-85
86 & above
Gender of senior
Male
Female
Proposed start date of service
How many days a week needed
List specfic days if applicable
Specific hours like 8am-5pm, 1pm- 9pm, 8am-5pm, 24 hour live-in
Preferred gender of caregiver
No preference
Male
Female
Budget per hour
$16-$20
$20-$30
$30-$40
How many hours would you need in a week?
4-10 hours
11-20 hours
21-40 hours
More than 40 hours
Please tell us how you heard about us
Please choose one
Google search
Craiglist
One of our care recipients
Drive by
One of our students
One of our workers
Other
Please write your mailing address if you would like to receive our package in the mail
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