Take the First Step

Request Care

Complete the form below and a care coordinator will contact you within one business day to discuss your needs.

Your information is encrypted and securely stored. We will never share your personal information without your consent.

Your Contact Information

Your Name *

Phone Number *

Email Address *

Preferred Contact Method

Client Information

Client Name *

Date of Birth

Care Needs

Service Requested *

Preferred Start Date

Preferred Schedule

General Information / Care Needs

Insurance Information

Optional — provide if you plan to use insurance for home care services.

Insurance Provider

Member ID

Group Number

Policy Holder Name

Relationship to Policy Holder

Additional Information

By submitting this form, you consent to Luxa and Care Home Services contacting you regarding your care request. Your information is kept strictly confidential and will not be shared without your consent. See our Privacy Policy.