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New Client Request Form
Welcome to Community Home Health Care! We are delighted that you have chosen us to be a part of your healthcare journey. As you begin this process with us, we want to extend a warm and compassionate welcome. We understand that reaching out for care and support can be a significant decision, and we commend you for taking this important step toward improving your well-being. By filling out our service request form, you have initiated a pathway to receiving the highest quality care and assistance from our dedicated team. This form will help us start the process and get to understand your unique needs and aspirations, allowing us to tailor our services specifically to you. Your voice matters, and we're here to support you every step of the way!
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  • Myself
  • Spouse
  • Parent
  • Grandparent
  • Daughter/Son
  • Other
  • Under 18
  • 18-30
  • 30-50
  • 50-70
  • 70-85
  • 85 and older
  • Living alone at home
  • Living with family
  • Assisted living
  • Nursing home
  • Other
  • A few hours per week
  • More than 20 hours per week
  • 40 or more hours per week
  • Around the clock
  • Private Funds
  • Long-Term Care Insurance
  • Medicaid Waiver Program
  • Other

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