Thank you for your interest in Nima Care Inc. Please complete the form below, and our care coordinator will contact you within 24 hours to schedule your free, no-obligation consultation.

Primary Contact Information

Your Name

Relationship to Client

Email Address

Best Phone Number to Reach You

Best Time to CallMorningAfternoonEvening

Potential Client Information

Client's First Name

Client's Last Name

Client's Date of Birth

Client's Address (where care will be provided)

City State Zip Code

Desired Care Services

Please check all that apply:

Companionship & ConversationMeal Preparation & Feeding AssistanceBathing, Grooming, & Personal CareDressing AssistanceMedication RemindersMobility & Transfer AssistanceToileting & Incontinence CareLight Housekeeping (e.g., laundry, tidying)Grocery Shopping & ErrandsTransportation to AppointmentsOvernight Supervision / SafetyRespite Care for Family CaregiverOther

If "Other", please specify:

Scheduling & Urgency

When are you looking to start care services?Immediately (Within the week)Within 2-4 weeksJust gathering information for the future

What is the preferred schedule?
(Check all that apply)Weekday MorningsWeekday AfternoonsWeekday EveningsOvernightsWeekends24/7 Live-In CareFlexible / As-Needed

Tell Us More About the Situation

What is the primary reason you are seeking care at this time?

Please list any key medical conditions or mobility concerns we should be aware of

How Did You Hear About Us?

—Please choose an option—Internet Search (e.g., Google, Bing)Social Media (e.g., Facebook)Referral from a Friend/FamilyReferral from a Healthcare ProfessionalOther

I agree to the Nima Care Inc. Privacy Policy.