Request Service - Blaine Health Services LLC

Service Request Form

Please fill out this form completely so we can better understand your needs and provide you with the best possible care.

Personal Information

First Name *

Last Name *

Email Address *

Phone Number *

Service Address

Street Address *

City *

State *

ZIP Code *

Services Requested *

Please select all services you are interested in:

Assisted Living Services

Comprehensive daily living support including dressing, eating, bathing, medication management, and 24/7 awake staff

Transportation Services

Safe, reliable transportation and hands-on assistance with transfers and mobility

Housing Stabilization Services

Support to find, obtain, and maintain stable housing

Support Planner Services

Comprehensive care coordination and service planning

Additional Information

Preferred Start Date

Special Requirements or Medical Conditions

Emergency Contact

Emergency Contact Name

Emergency Contact Phone

By submitting this form, you agree to be contacted by Blaine Health Services regarding your service request.

What Happens Next?

Here's what you can expect after submitting your service request

Initial Contact

We'll contact you within 24 hours to discuss your needs and answer any questions you may have.

Free Consultation

We'll schedule a free in-home consultation to assess your needs and create a personalized care plan.

Care Begins

Once you approve the service plan, we'll match you with the right support staff and begin services.

Request Our Services