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Private Pay Services

1

Homemaker

Revamp Care Provides dependable homemaker services designed to help individuals maintain a clean, comfortable, and organized living environment. Our services include light housekeeping, laundry, linen change, meal preparation, and general household organization. We help make daily living easier by maintaining a welcoming home where clients can feel comfortable and supported.

2

Companionship

Revamp Care offers compassionate companionship services focused on promoting social engagement, emotional well-being, and independence. Our companions provide friendly conversation, participate in hobbies and recreational activities, assist with reading and games, and offer meaningful social interaction. Whether spending time together at home or accompanying clients on approved outings, we strive to reduce feelings of loneliness and help each individual enjoy a more fulfilling daily routine.

INTERESTED IN PRIVATE PAY

Contact Revamp Care today to discuss you needs, explore service options, and receive information about our private pay rates. Let us help you create a more comfortable, supported, and fulfilling daily life at home.

Fill out the intake form below to get started.

CLIENT INFORMATION

Birthday
Month
Day
Year
Multi-line address
Do you live alone?
Yes
No
Who is requesting services?
Individual seeking services
Family member / Caregiver
Waiver Support Coordinator
Facility / Referral Source
What are your schedule needs?
Weekdays (Day Shift)
Weekdays (Evening Shift)
Weekdays (Overnight Shift)
Weekends (Day Shift)
Weekends (Evening Shift)
Weekends (Overnight Shift)
Flexible
How will services be covered?
Private Pay
Medicaid
Insurance
Requested Services
Homemaker
Companionship
Both
Do you have any chronic conditions?
Yes
No
Do you have any mobility issues?
Yes
No
Are there any pets in the home?
Yes
No

EMERGENCY CONTACT INFORMATION

NAME OF PHYSICIAN

MEDICAL INFORMATION

INSURANCE INFORMATION

CONSENT & AUTHORIZATION

I CERTIFY THAT THE INFORMATION PROVIDED IS ACCURATE TO THE BEST OF MY KNOWLEDGE. I AUTHORIZE REVAMP CARE LLC TO PROVIDE NON-MEDICAL HOME CARE SERVICES AS AGREED UPON.

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