Carelistening | Companion Care & Transportation

Client Information

Client Full Name *

Phone Number *

Email Address

Service Address *

Who Is Requesting Service?

Select the option that best describes you

Self-Pay ClientPower of Attorney / Family RepresentativeGuardian / Authorized Representative

Emergency Contacts

Emergency contacts will be notified in the event of an emergency.

Primary Emergency Contact

Contact 1 Name *

Contact 1 Phone *

Secondary Emergency Contact (Optional)

Contact 2 Name

Contact 2 Phone

Mobility Level

Preferred Schedule

Select all days and times that work best for you.

Days of the Week

Time of Day

morningafternoon

Preferred Start Time

e.g., "9:00 AM" or "2:30 PM"

Hours Per Session

How many hours per visit?

Services Requested

Select all services you are interested in.

Companion Visit$45/hour

Appointment Accompaniment$15/hour

Errands & Essential Trips$35/hour

Transportation$25 base + $2/mile

Wellness Check-In Call or Visit$6/call or $20/week

Monthly Support Package$300/week + mileage

Plan of Care

What would you like us to focus on during visits?

Comments / Service Needs

Client Service Agreement

A signed agreement is required before services begin.

Review Client Service Agreement Download PDF

Required Acknowledgments

All four items must be checked before submitting.

I understand that Carelistening Transportation & Companion Services LLC provides non-medical services only.

I agree to the Terms & Conditions, payment rules, cancellation policy, and service limitations.

I acknowledge the liability waiver and understand that emergencies may require calling 911 and contacting emergency contacts.

I understand that in an emergency, Carelistening may contact 911 and provide reasonable assistance until emergency responders arrive, in accordance with applicable Good Samaritan protections under New Jersey law.

By submitting this form, you agree to all acknowledgments above. Carelistening will contact you to confirm scheduling.

Client Intake Form