Family intake

Tell us what kind of help you need.

A short intake with the minimum details we need to start staff triage. We log your permissions separately so outreach and facility sharing stay explicit.

First nameLast nameEmailPhonePreferred contact methodRelationship to residentDesired city or areaLaunch marketMove-in timeframeGeneral care categoryBudget minimumBudget maximum I want help scheduling calls or tours.I have reviewed the privacy notice and understand Assisted Living Help will use my information to review this request.I agree that Assisted Living Help may contact me about matching and scheduling support.Channel permissions

Email follow-up allowed SMS follow-up allowed Phone call follow-up allowed

I agree that Assisted Living Help may share my information with facilities only to coordinate next steps for this request.

Email and SMS follow-up are manual for now. We do not claim live availability, and we do not share your details with facilities unless you gave sharing permission.