For Families

Family Care Intake Form

Tell us who needs care and what matters most to your family. It takes about 3 minutes, and we'll follow up with caregiver matches that fit your preferences.

Family eligibility checklist

Before you submit, here's what our family intake covers. Most families who reach out look like this:

You need care in Los Angeles County, San Bernardino County, or a neighboring Southern California region.
The person receiving care is at home, in assisted living, or transitioning home from a facility.
You're hiring a caregiver directly (we're a referral marketplace, not a staffing agency).
You have a general idea of the schedule and hourly budget you can support.
You (or an authorized family member) can sign the care agreement and handle payment directly with the caregiver.

Not sure if you qualify? Submit the form anyway — our team will review and point you in the right direction.

Your contact details

Full name *

Email *

Phone

City

County where care is needed *

Who needs care?

Care preferencesType of care needed *Select all that apply.

Preferred scheduleSelect all that apply.

Preferred caregiver languages

When do you need to start?

Hours needed per week

Budget range

Caregiver gender preference

Anything else we should know?Conditions, house rules, pets, parking, etc.

Supporting documents (optional)

You may attach a photo ID, proof of eligibility, benefit letters, or any care documents. PDF, JPG, PNG or WEBP, up to 5 MB each.

Document type

Uploading documents is optional — you can send them later by email.

Consent & privacy notice

We use your contact details and care preferences only to match your family with independent caregivers and to follow up about your request.
Limited details (county, care needs, schedule) may be shared with caregivers we introduce to you — never your full address or payment information.
A Place to Connect is a matching platform. Caregivers are independent contractors, not our employees.
We never sell your information. You can ask us to update or delete your submission anytime by emailing aplacetoconnectla@gmail.com.
Your unfinished form is autosaved in this browser only so you can resume later. Choose “Start over” on a shared computer to erase it.

I have read and agree to this notice. * I consent to A Place to Connect storing and using the information I provide as described above, and to being contacted by email, phone, or text about my request. See our Terms & Privacy.

Family FAQs — answered before you submit

How much does it cost to use A Place to Connect?

Submitting an intake form is free. Families pay caregivers directly at the rate you agree on. An optional $39/month Family Membership unlocks direct contact details and messaging with caregivers on the platform.

How quickly will I hear back?

Our team reviews new intake forms and follows up within 1–2 business days by phone or email. You'll get a reference number by email right away and can track progress on the request status page.

Are caregivers screened?

Caregivers on the platform agree to our code of conduct, must have current CPR & First Aid verification before placement, and many carry HCA registry credentials. Families interview and hire caregivers directly, so we always encourage your own interviews and reference checks.

Do you employ the caregivers?

No. A Place to Connect is a referral marketplace. Caregivers are independent contractors, and you arrange care, scheduling, and payment directly with the caregiver you choose.

What if I also need housing help?

We run a separate housing referral program for veterans, women 55+, and respite care in San Bernardino and Los Angeles counties. Visit our Find Housing page to join the waiting list.

What information should I have ready?

Your contact details, the city and county where care is needed, the type of help required, days and hours you need covered, your target hourly budget, and any conditions or house rules we should know about.