Companion at Will — Client Intake Form

Section 1 — Client Information

First Name *

Last Name *

Date of Birth *

Gender

Home Address *

City

ZIP Code

Phone Number *

Alternate Phone

Email Address

Preferred Pronouns

Primary Language

Section 2 — Emergency Contact

Emergency Contact Full Name *

Relationship to Client *

Phone Number *

Secondary Emergency Contact

Relationship

Phone Number

Emergency Instructions

Section 3 — Medical & Mobility Information

This information is used only to keep you safe during services. We are not a medical provider.

Primary Care Physician (Name & Phone)

Known Medical Conditions General information only. Do not include detailed medical records.

Current Medications

Known Allergies

Mobility Status — Please check all that apply:

Independent — walks without assistance Uses a cane Uses a walker Uses a wheelchair (manual) Uses a wheelchair (electric/power) Requires hands-on transfer assistance Other

Section 4 — Service Preferences

Preferred Stores or Locations

Preferred Time of Day

Morning (8am–12pm) Afternoon (12pm–5pm) Evening (5pm–8pm) Flexible — no preference

Typical Trip Duration

How Often Do You Need Service?

Types of Assistance Needed — Check all that apply:

Grocery / errand runs Medical appointment transport Social outings / activities In-home companionship / conversation Medication pickup (pharmacy) Light meal preparation assistance Other

Additional Notes or Special Requests

Section 5 — Authorized Parties

List anyone authorized to coordinate services or make decisions on your behalf.

Authorized Person #1 — Name & Relationship

Authorized Person #2 — Name & Relationship

Authorized Person #3 — Name & Relationship

Section 6 — How Did You Hear About Us?

How did you hear about us? Please check all that apply:

Referral (Friend / Family) Senior Community / Residence Church / Ministry Facebook / Social Media Online Search Other

Section 7 — Select Your Service Level

At Companion at Will, we come to you — we are a fully mobile, community-based companionship service. We do not operate out of a building. Our companions meet you at your home, your community, or wherever you need us.

Please select the service level that best fits your needs. A Companion at Will representative will review your selection and confirm your care plan.

Which service level best describes your needs? *

🟢 Low Need Companionship — $25/hour
Occasional companionship, light errands, social visits, friendly check-ins. Approx. 2–4 hours weekly. 🟡 Moderate Need Companionship — $30/hour
Recurring companionship, transportation, multiple weekly visits, routine support. Approx. 5–10 hours weekly. 🔴 High Need Companionship — $35/hour
Frequent visits, extended sessions, wellness check-ins, family communication support. 10+ hours weekly. 🕊️ Hospice & End-of-Life Companionship — $50 Flat-Rate Visit
Compassionate presence, quiet visits, prayer, reading, music, family respite support. I'm not sure — please help me choose
A representative will contact you to discuss the best fit.

Payment Accepted: Cash | Zelle | Credit/Debit Card | Check
We do not accept insurance at this time.

Holiday Rate: Standard rates may increase by $5/hour during major holidays due to limited scheduling availability.

Important: Companion at Will provides non-medical companionship services only. We do not provide hands-on medical care, nursing services, or personal care assistance requiring licensure.

By submitting this form, I confirm that the information provided is accurate to the best of my knowledge and I consent to its use for service coordination purposes only. All information will be kept strictly confidential.

Section 1 — Client Information

Section 2 — Emergency Contact

Section 3 — Medical & Mobility Information

Section 4 — Service Preferences

Section 5 — Authorized Parties

Section 6 — How Did You Hear About Us?

Section 7 — Select Your Service Level

Thank You!