Request Care or Staffing Care Type * Select Care TypeDirect/Home Health Care (Family or Patient)Healthcare Facility Staffing (Hospital, Nursing Home, Rehab) Email Address * Home Care Request Your Name * Phone Number * Who Are You Seeking Care For? MyselfParentSpouse / PartnerOther Family MemberFriendOther If Other, Please Specify Preferred Contact Method PhoneEmail Care Location City * State * ZIP Code * Where Will Care Be Provided? Private HomeApartment / Senior CommunityAssisted Living SettingOther If Other, Please Specify Type of Home Care Needed Select all that apply. Companion CarePersonal Care AssistanceRespite CareDementia / Memory SupportAlzheimer's SupportMeal PreparationLight HousekeepingMobility / Ambulation AssistanceBathing / Grooming AssistanceMedication RemindersTransportation / ErrandsSafety SupervisionPost-Hospital / Recovery SupportOther Other Care Needed How Often Is Care Needed? A Few Hours Per WeekSeveral Days Per WeekDaily SupportOvernight SupportWeekend SupportRespite / Occasional SupportNot Sure Yet — I Would Like Guidance Schedule & Consultation Preferred Start Date Preferred Schedule MorningAfternoonEveningOvernightWeekdaysWeekendsFlexible / To Be Discussed Tell Us How We Can Help Best Time for ElandCare to Contact You MorningAfternoonEvening Facility Staffing Request Facility / Organization Name * Contact Person * Title / Role Director of NursingStaffing Coordinator / SchedulerAdministratorExecutive DirectorHuman ResourcesOther If Other, Please Specify Phone Number * Facility Address Street Address City * State * ZIP Code * Staffing Need Type of Staff Needed Certified Nursing Assistant (CNA)Licensed Practical Nurse (LPN)Registered Nurse (RN) Number of Staff Needed 1234–56+ Type of Coverage Needed Same-Day / Urgent CoveragePRN / Per DiemShort-Term CoverageContract StaffingOngoing Staffing SupportWeekend CoverageOther If Other, Please Specify Facility Type Skilled Nursing FacilityNursing Home / Long-Term CareRehabilitation CenterAssisted LivingMemory CareHospiceHome HealthHospitalOther If Other, Please Specify Shift Details Requested Start Date Shift Date(s) Shift Start Time Shift End Time Shift Type Day ShiftEvening ShiftNight ShiftWeekday CoverageWeekend CoverageOngoing / Recurring Coverage Unit or Department Skilled NursingRehabilitationMemory CareAssisted LivingLong-Term CareHospiceHome HealthOther If Other, Please Specify Additional Information Additional Staffing Details Urgency As Soon as PossibleWithin 24 HoursWithin 2–3 DaysWithin 1 WeekFuture / Planned Coverage Please leave this field empty.
