CareMatch Pros
by AMS
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1
Contact information
First name
Last name
Email address
Telephone number
Preferred contact method
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Telephone call
Text message
Email
Best time to contact
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Morning
Afternoon
Evening
I am requesting assistance for
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Myself
A family member
A friend
A client or patient
Another person
2
Person needing services
First name or initials
Age range
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Under 18
18–21
22–54
55–61
62–64
65–74
75–84
85 or older
Veteran status
Select one
Yes
No
Unsure
Prefer not to answer
Current living situation
Select one
Own home or apartment
Living with family or friends
Hotel or temporary lodging
Shelter
Hospital or rehabilitation facility
Correctional or reentry setting
Treatment facility
Vehicle or outdoors
Current housing is unsafe
Other
3
Location and services
State where service is needed
Select state
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
County
City
ZIP code
Services needed
Select all that apply
Non-medical home care
Home health services
Independent living
Assisted living
Veteran housing
Shared housing
Permanent supportive housing
Transitional housing
Sober living
Adult foster care / adult family home
Developmental-disability group home
Maternity group home
Reentry housing / halfway house
Co-housing community
Single-room occupancy housing
Meal delivery
Non-emergency medical transportation (NEMT)
Other supportive service
Unsure — guidance needed
4
Payment and accessibility
Expected payment source
Select one
Private pay
Medicaid
Medicare
VA benefit or program
Housing voucher
Social Security income
Disability income
Employment income
Grant-funded program
Insurance
Family assistance
No current payment source
Unsure
Other
Accessibility accommodations needed?
Select one
Yes
No
Unsure
Prefer to discuss privately
Mobility
Select if applicable
Independently mobile
Uses a cane or walker
Uses a wheelchair
Needs assistance transferring
Needs assistance with mobility
Prefer to discuss privately
General accommodations or support areas
5
Readiness and consent
Most important requirement for a successful match
Anything else we should consider?
I confirm this information is accurate and I am authorized to submit this inquiry.
I consent to CareMatch Pros contacting me about this request.
I authorize CareMatch Pros to share the minimum relevant information with selected participating providers.
I understand CareMatch Pros may receive membership, advertising, marketing, or lead-generation fees, and submission does not guarantee placement or acceptance.
Submit my inquiry
Your inquiry will be stored directly with CareMatch Pros. No email application will open.
