Let's Talk About What Matters Most

Care You Can Trust. Comfort You Can Feel.

Whether you’re here to request care, ask questions, or simply connect—we’re ready to listen.
This is where peace of mind begins, and comfort becomes a conversation. From families seeking trusted support to compassionate caregivers ready to serve, Sweet Tea Home Care™ is here for you. Reach out below—and let’s start with heart.

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Care Needs - Step 1 of 4

At Sweet Tea Home Care, we believe everyone deserves compassionate, respectful, and dependable support. Please share the information below so we can better understand your needs and create a personalized care plan for you or your loved one.

“This intake form is the first step. Care is not active until assessment and contract are complete.

”All information provided is confidential.

Primary Contact Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Birth Date: *

Preferred Way to Connect *

Phone Call
Text Message
Email

Best Time to Contact You: (copy) *

Is this request urgent?*

Yes – Care needed within 48 hours
Within 1 week
Planning ahead

Preferred Start Date for Service Request: *

(Examples: 02/01/2024, specific date )

What type of care are you seeking? (Select all that apply) *

Personal Home Care
Post-Hospital Recovery Support
Dementia & Memory Support
Chronic Illness Support
Companion Care & Lifestyle Support
Light Housekeeping
Meal Preparation
Other

Select all that apply.

Who Is the Individual Requiring Care? *

Myself
Loved one

If for a loved one, please provide their full name: *

Location Where Care Will Be Provided (Street Address, City, State, ZIP Code) *

(If different from above, please include full address. Otherwise, write “Same.”)

Is a Power of Attorney or Legal Guardian in Place? *

If yes, please provide their name and contact information:

Does the individual have any medical conditions we should be aware of? (e.g., diabetes, dementia, stroke)? *

If yes, please describe:

Mobility Status *

Fully Independent
Uses Walker
Uses Wheelchair
Requires Transfer Assistance
History of Falls
Other

Select all that apply.

Is Assistance Needed With Any of the Following Activities? *

Bathing
Dressing
Grooming
Toileting
Transferring (bed/chair)
Eating
Light Housekeeping
Meal Preparation

Select all that apply.

Has the individual experienced any falls within the past 6 months? *

Is assistance needed with medication reminders or appointment management? *

Are There Any Known Allergies (Food, Medication, or Environmental)?

If yes, please specify:

Is Any Medical Equipment Used in the Home (e.g., oxygen, catheter)? *

If yes, please specify (oxygen, catheter, hospital bed, etc.): *

Do you live alone or with someone? *

Lives Alone
Lives With Family or Others

Do you feel safe at home? *

What type of home do you live in? *

Single-Family Home
Apartment
Assisted Living
Other

Are there stairs or safety concerns in the home? *

Are smoke detectors and emergency contacts easy to reach? *

What does a typical day look like for you? *

Are there tasks you find difficult or would like help with? *

Do family, friends, or neighbors help you now?

Are there memory concerns or confusion? *

Has the individual experienced feelings of loneliness, anxiety, or low mood recently?

Would companionship or structured activities be helpful?

Emergency Contact Name & Phone Number *

Transportation Needs *

Drives Independently
Requires Transportation Assistance
Public Transportation
Other

Following or

What qualities are most important in a caregiver? *

Are there cultural, religious, or personal preferences we should honor?

Do you prefer a male or female caregiver (if available)?

Male
Female
No preference

What activities bring joy or comfort? *

“What kind of schedule would work best? *

Have you previously used home care services?

If yes, what did you like or dislike about your previous service?

How did you hear about Sweet Tea Home Care? (For example: referral, healthcare provider, Google search, Facebook, Instagram, friend or family member.) *

Media Consent

Sweet Tea Home Care - Photo Release Agreement

This agreement is between Sweet Tea Home Care and the undersigned individual. By agreeing below, you grant permission for Sweet Tea Home Care to photograph, record, or capture your image, voice, or likeness for lawful business purposes, including website content, educational materials, and promotional use. You understand that: Participation is voluntary No financial compensation will be provided Media use is at the discretion of Sweet Tea Home Care Consent may be revoked in writing with 30 days’ notice (excluding previously p

By signing below, the Participant agrees to the terms above. *

I agree to the following terms.
I disagree to the following terms.

Name *

First

Last

Date / Time *

Date

Time