Call: (218) 303-5838 | Email: info@yourplacellc.org | Free Consultation Available | Private-Pay Non-Medical Support

Get Help

Whether you need support for yourself or want to refer someone in your community, getting started is simple.

Call (218) 303-5838 Submit a Form

Getting Started

How It Works

Contact Us

Call us or fill out the Client Intake Form (for yourself) or Community Referral Form (to refer someone).

We Learn About Your Needs

We review your information and reach out to discuss the individual’s situation, preferences, and goals.

We Create a Support Plan

We recommend flexible private-pay support options tailored to your needs.

Support Begins

A trusted companion provides scheduled non-medical support.

Choose Your Form

Start Your Request

Select the form that best fits your situation.

Client Intake Form

For individuals seeking support for themselves or a loved one. This form helps us understand your needs so we can provide the best possible service.

Complete this form so we can learn about your needs and connect you with the right support. All information is kept strictly confidential.

1. Client Information

Full Name *

Date of Birth

Age

Gender

Street Address *

City *

State

Zip Code

Phone Number *

Email Address

Best Way to Reach You Phone CallText MessageEmail

Preferred Language

Current Living Situation

How did you hear about us?

2. Emergency Contact

Primary Emergency Contact

Contact Name *

Relationship to Client *

Phone *

Secondary Emergency Contact (Optional)

Contact Name

Relationship

Phone

3. Caregiver Information

Do you currently have a caregiver? YesNo

Caregiver Name

Relationship to Client

Caregiver Phone

Caregiver Email

Caregiver currently assists with: AppointmentsTransportationPersonal CareHousehold TasksMedication RemindersMeal PrepOther

4. Services You Are Interested In

Check all that apply: * Companion Care & Wellness SupportResource Navigation & Community ConnectionsAppointment Accompaniment & Errand SupportCommunity Engagement & Social ConnectionWorkforce NavigationCaregiver Support ResourcesSenior Services InformationHousing & Community ResourcesBenefits & Financial Assistance InfoVolunteer OpportunitiesOther

5. Mobility & Accessibility

Do you use any mobility devices? NoneCaneWalkerWheelchairMotorized ScooterOther

Are there stairs in your home? YesNo

Need help entering/leaving home? YesNo

Any other mobility or accessibility needs?

6. Transportation

Do you currently drive? YesNo

Reliable transportation available? YesNo

Interested in appointment accompaniment? YesNoMaybe

Want community transportation info? YesNo

Please Note: Your Place LLC does not provide stand-alone transportation. Appointment accompaniment may be available as part of scheduled companion visits.

7. Tell Us More

Share any goals, concerns, or information that will help us support you:

Acknowledgment & Consent

I understand that Your Place LLC provides non-medical companion and community support services.

I understand that services are private-pay.

I understand that Your Place LLC is NOT a medical provider, home health agency, transportation company, legal service, or financial advisory service.

I understand that transportation may only be provided as part of a scheduled companion visit.

Community Referral Form

For community partners, organizations, and individuals referring someone who could benefit from our services.

Used by: Churches Hospitals Clinics Social Workers Senior Centers Home Health Agencies Caregiver Programs

Refer an individual to Your Place LLC services. Referrals can be submitted by community partners, healthcare providers, social workers, family members, or as self-referrals. All information is confidential.

Referral Source

Your Full Name *

Organization / Agency

Your Title / Role

Type of Referral *

Your Phone *

Your Email *

Individual Being Referred

Full Name *

Date of Birth

Phone

Address

County

Preferred Language

Living Situation

Preferred Contact Method PhoneTextEmailMail

Reason for Referral

Services Requested * Companion Care & Wellness SupportResource Navigation & Community ConnectionsAppointment AccompanimentCommunity Engagement & Social ConnectionWorkforce NavigationCaregiver Support ResourcesOther

Urgency Level Low — General inquiry / no rushMedium — Support needed within 1-2 weeksHigh — Urgent support needed

Reason for Referral *

Mobility or Accessibility Considerations

Emergency Contact (for Individual)

Contact Name

Relationship

Phone

Acknowledgment

I confirm that the individual is aware of this referral, or I am authorized to submit it on their behalf.

I understand that Your Place LLC provides non-medical companion and community support services only.

Important Service Information

Your Place LLC provides private-pay companion and support services.
Your Place LLC is not a medical provider, home health agency, transportation company, legal service, financial advisory service, or emergency response provider.
Transportation may only be provided as part of a scheduled companion visit when appropriate. Stand-alone transportation services are not offered.

For emergencies, please call 911.

Prefer to Reach Out Directly?

Contact Us

You can also reach us by phone or email. We’re happy to answer questions and discuss how we can help.

(218) 303-5838 Call us anytime info@yourplacellc.org Email us

Ready to Get Started?

Whether you need support for yourself, a loved one, or want to refer someone in your community, we’re here to help.

Call (218) 303-5838 Submit a Form