Request Services

Compassionate Care Starts Here. We understand that time and life unfold differently for everyone, bringing unique challenges.

This form allows you to request services and begin the intake process. Submitting this request does not guarantee services. Our team will review your information and contact you to discuss eligibility, availability, and next steps.

Destiny Cares Service Request Form

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Client Information Section

Name *

First

Last

Date Of Birth *

client describe. Consent

Address *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone *

Email *

Assisting The client?

Are you completing this form on behalf of the client?

• No, I am the client.
• Yes, I am assisting the client.

Name *

First

Last

Relationship *

Relation to Client.

Phone *

Email *

Guardian Section

Does the client have a legal guardian, conservator, or authorized representative? *

• Yes
• No, the client makes their own decisions.
• Not Sure

If the client has a legal guardian, conservator, or authorized representative, please complete the information below.

Name *

First

Last

Relationship *

Connection to Client

Phone *

Email *

Service & Coverage Information

Primary Coverage Type *— Select Choice —MedicaidMedicareMedicaid + Medicare (Dual Eligible)Minnesota HCBS WaiverNorth Dakota HCBS WaiverManaged Care Plan (e.g., UCare, Blue Plus, etc.)Private PayNot Sure

Case Manager Name *

First

Last

Email *

Phone *

Is the client currently receiving services? If yes, please describe. *

What type of assistance is needed? (Select all that apply) *

• Bathing
• Dressing
• Grooming & Hygiene
• Toileting
• Meal Preparation & Planning
• Medication Reminders (non-administration)
• Mobility & Transfer Assistance
• Community Participation Support
• Light Housekeeping
• Moderate Housekeeping
• Social Engagement & Safety Supervision
• Behavioral Support
• Respite Care
• Other

Please describe the client’s current care needs in detail? *

Select the days services are needed *

• Monday
• Tuesday
• Wednesday
• Thursday
• Friday
• Saturday
• Sunday

Please specify requested times for the selected days. *

Example: Monday 8AM–12PM, Wednesday 2PM–6PM

Next

Health & Safety Screening

The following questions help us determine appropriate service placement.

Does the client currently require skilled nursing services? *

• Yes
• No
• Not Sure

Is the client currently hospitalized or in a skilled nursing facility? *

• Yes
• No

Does the client have any communicable conditions requiring isolation precautions? *

• Yes
• No
• Not Sure

Does the client exhibit behaviors that may pose a safety risk to themselves or others? *

• Yes
• No
• Not Sure

What mobility equipment does the client use? (Select all that apply) *

• None
• Walker
• Wheelchair
• Hoyer Lift (Full Body Lift)
• Standing Lift (Sit-to-Stand Lift)
• Hospital Bed
• Not Sure

Consent & Authorization

Please review and confirm the following before submitting your request.

Accuracy Certification *

• I certify that the information provided is accurate to the best of my knowledge.

Contact Consent *

• I consent to be contacted by Destiny Cares LLC regarding service coordination and eligibility verification.

No Guarantee Disclaimer *

• I understand that submission of this form does not guarantee service placement.

Are you completing this form on behalf of the client? *

• Yes
• No

Authorization Confirmation *

• I confirm that I am authorized to provide this information on behalf of the client.

Custom Captcha *

What is 22+35

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