Name

First Name

Last Name

Phone

(###)

###

####

Which of the following may be useful?

You may select multiple options.

Finding me a therapist

Connecting me with support groups

Helping me manage medications

Scheduling appointments

Researching different products

Support with insurance reimbursement

Guidance on managing finances

Ordering groceries

Managing rides and transportation

Do you agree to Hometeam's Terms of Service and Privacy Policy? *

The Terms of Service and Privacy Policy are linked at the bottom of this webpage. Hometeam does NOT provide any medical, legal, or financial advice. In case of an emergency dial 911. Hometeam may identify third parties who perform services that are useful to family caregivers, but Hometeam does NOT endorse any third party services, and makes NO representation or warranty whatsoever regarding third parties or third party services.

Yes

No

Do you agree to Hometeam's Electronic Communication Policy? *

The Electronic Communication Policy is included in the Terms of Service linked at the bottom of this webpage. Hometeam uses a HIPAA compliant texting platform. By checking "yes" you herby consent and state preference to have Hometeam communicate with you by email or SMS messaging regarding the service. You understand that email and standard SMS messaging are not confidential methods of communication and may be insecure. You further understand that, because of this, there is a risk that email and standard SMS messaging regarding services might be intercepted and read by a third party.

Yes

No