Self-Directed Care Inquiry | Simpl Care

Individual Form

Individual Information

Your Name

Do you have a Legally Authorized Representative?

I am my own legally authorized representative looking for care for myself

Yes

I am my own legally authorized representative looking for care for myself

No

Guardian Name

Guardian Email

Guardian Phone Number

Will this person be providing services for you?

Yes

YesNo

No

Your Email

Your Phone Number

Individual Form

Case Manager Information

Case Manager Name

Case Manager Email

Case Manager Phone Number

Individual Form

Staff Information

Staff Name

Staff Email

Staff Phone Number

Add another staff

Individual Form

Service Information

What Services do you need?

Attendant Care

Caregiver Compensation

Companion Services

Homemaker

Host Home Supports

Personal Assistance Services

Respite

Supported Employment

Supported Living

What Services do you need?

Community Living Basic

Community Living Level 3+

Companion Services

Homemaker

Individual Habilitation

Personal Care

Respite

Supported Employment

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