Account Setup

Agency Owners Name*
First Last
Email*
Website
Agency Name / Name To Be Used In Text Messages*
Agency Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Agency Phone Number*
Service Areas*
Backup Phone Number / Cell Phone Number
You may receive text notifications, live call transfers from people requesting immediate care or from referral sources.
Intake Process
Intake Interview or Care Assessment
- Care assessments only
- Intake interviews only, we will schedule the care assessment.
Main Person Responsible for intake interviews or assessments*
First Last
Average Lifetime Value of a New Client or Patient
Help us learn more about your start of care admission process*
When someone inquires about your agency what do you usually ask? Eg. Location? Care Recipient Name? Gender? Age? Status? Condition? Level of Care? Type of assistance needed? How many hours per day or per week? Payment Method? How long does each step take? 1) Intake Interview 2) Care Assessment Process 3) Care Plan 4) Start Date. Please be as clear and as detailed as possible. Eg. We verify your insurance by phone and we schedule your care assessment with a nurse. We take Private pay, Private insurance, Medicare, Minimum hours are.. etc.
Intake Appointment / Care Assessment Time Slots*

Add Hours
Maximum Simultaneous Appts
Maximum Daily Appointments
Agency Specific Information
-Is your agency licensed and certified? -What type of insurance do you take? -List of affiliated insurance -Do you take medicare or medicaid? -Are there prerequisites before the client could undergo the care assessment or the start of service? -Pricing and pricing conditions -Any additional information such as payment details for clients.
Agency Discount Offer or Event
A proven offer, discount or virtual event that has worked for your agency. Eg. "THANK A VET" Discount Program.
Database Upload and Marketing Materials
(Rate sheet, care process, payment information, old inquiries, directory logins, brochures, start of care application, referral sources etc ).
By submitting this form, I acknowledge that I have and are giving permission to send marketing materials via SMS, email and other channels on my behalf to my clients customers or patients and am responsible for maintaining the confidentiality of my account and password, and I agree to accept responsibility for all activities that occur under my account and password.

By submitting this form, I acknowledge that I have and are giving permission to send marketing materials via SMS, email and other channels on my behalf to my clients customers or patients and am responsible for maintaining the confidentiality of my account and password, and I agree to accept responsibility for all activities that occur under my account and password.
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Name
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Account Setup

Intake Process

Database Upload and Marketing Materials