In Person Consultation Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

What to Expect at Your 15 to 30 Minute Consultation

Thank you for your interest in selecting Chrysalis Spectrum as a provider for personal assistant service. Chrysalis Spectrum is a nonmedical personal assistant service agency licensed by Texas Health and Human Services.

Chrysalis Spectrum is located 8300 Cypress Creek Parkway Ste 450, Houston, TX 77070 and serves residents throughout Greater Houston. We discuss the care needs of the person requesting the service. To help prepare for the conversation please know the following:

Email *

Expected start date *

YYYY

Diagnosis *

Gender *

Female

Male

Person needing care first name *

Person needing care last name *

Person needing care date of birth *

YYYY

Height *

Weight *

Can the person walk without assistance from devices (canes, wheelchairs, lifts)? *

Yes

The care needs *

Bathing, toileting, dressing, grooming, feeding, transfer & personal assistant service

Prompting, light housekeeping, meal preparation, errands, shopping, medication reminders

Sitter (visual observation)

Transportation

Required

The tentative schedule for care *

Part-time (between 4 to 20 hours a week)

Full-time (20+ hours a week)

As-needed

Short visit (less than 2 hours)

Please describe the tentative schedule. For example the days of the week, start and end time, or specific date you are needing service. *

Caregiver preference *

Female

Male

Caregiver area of expertise *

Senior care (dementia or Alzheimer's)

Intellectual developmental disability

Physical disability

Experience with toileting, showers, dressing, grooming, and transfers

Required

Street Number *

Street name *

City *

State *

Zip Code *

Chrysalis Spectrum hourly rate is between $21 to $25 per hour. Prior to the start of care there is a nonrefundable retainer fee for service. *

Yes, I understand.

No, I do not want to move forward with process.

Required

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Chrysalis Spectrum. Report Abuse

Forms