NWFL Companion & Respite Client Intake Form

This form is for non-medical companion and respite services only. Please note that NWFL Companion & Respite does not provide emergency or medical care; for emergencies, please dial 911.

NWFL Companion & Respite Client Intake Form

Non-medical companion and respite services intake. Please complete all fields as thoroughly as possible.

Full name*

Email address*

Phone number*

Preferred method of contact*

Phone

Text

Services requested*

Companion Care

Respite Care

Social companionship

Conversation and companionship

Games, hobbies, reading, TV/movies, walks, and other recreational activities

Accompanying the client on appropriate outings or appointments

Caregiver relief / family respite

Desired start date*

Preferred days of the week*

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

How many hours per day do you want?

Services We Do Not Provide

NWFL Companion & Respite provides non-medical companionship and respite services. We do not provide medical care, nursing services, medication administration, medical treatments, skilled nursing, wound care, injections, or other skilled medical services. We also do not provide house-cleaning services, deep cleaning, heavy housekeeping, construction, yard work, or other specialized household labor. Our purpose is to provide companionship, social interaction, appropriate assistance during companion visits, and respite for family caregivers within our approved service scope.

Tell us anything else you would like NWFL Companion & Respite to know about the client or the type of companionship/respite being requested

I understand that NWFL Companion & Respite is a non-medical companion and respite service and that submitting this intake form does not guarantee that services will be accepted or scheduled.

Providing trustworthy companion and respite care with warmth and professionalism across Northwest Florida.

nwflcompanionandrespitellc@gmail.com

Pace, Milton, Northwest Florida, Crestview, Navarre, Gulf Breeze

Phone: 850-781-2823

NWFL Companion & Respite is not an emergency medical service. If you or someone else is experiencing a medical emergency, call 911.

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