Free Online Assessment

Step 1 • Contact Info | Step 2 • Needs Assessment | Step 3 • Facility Search

To better assist your needs we have developed a unique online system that will help you find the best health care options for you or your loved one. Please provide as much information as possible.

*First Name
*Last Name
Company (if applicable)
*Phone	(i.e. 9169249111)
Email
Address (optional)
*City
*State
Zip Code
What is your relationship with the person for whom you are seeking assistance?*

How did you hear about us?*
Terms & Conditions FOR CARE HOME REFERRALS CLIENT INFORMATION. Client shall provide Agency with information on Client's health, mental, social, and physical condition in order to assist Agency in determining which facilities will be suitable for Client. Client hereby authorizes Agency to disclose said information to prospective facilities in order for facilities to evaluate Client for possible placement. CLIENT COOPERATION. Client agrees to identify Agency as the referral source when Client tours a facility referred by Agency and notify Agency of each facility tour taken. HOLD HARMLESS - Client agrees and understands that Agency, while making every reasonable effort to match Client with a suitable facility, accepts no responsibility for any negligence or misconduct by any facility referred to Client. The final decision as to which facility will be chosen shall be solely based on Client's assessment of each facility. Client shall not rely on information from Agency as the sole basis for choosing a facility. Any claims by Client against a facility referred by Agency, for any reason, shall be solely between Client and the facility. Agency shall not be liable to Client, and Client hereby agrees to waive any claims against Agency for any damages caused by a referred facility to Client. NO COST TO CLIENT. Client understands that Agency's services performed herein shall be at NO COST to Client. The only consideration from Client shall be Client's cooperation as stated above. Client also understands that Agency will be paid a referral fee from the facility when Client is placed into a facility referred by Agency.
I have read, understood and agree to the above Terms and Conditions and ApexCare Privacy Policy*