Family intake

Tell us what kind of private support you need.

Share the support your family is looking for. Hope uses this request to understand your needs and help identify possible private providers. Your family membership is $10 per month or $60 per year, and monthly membership may be canceled anytime. You coordinate service details, scheduling, and service payment directly with the provider you choose.

Parent, Guardian, or Adult Client Full name Email Phone City and state ZIP code Preferred search radius

Who Needs Support? Support is for Age or age range Preferred service setting Helpful context

Service Categories Other or unknown need

Safety Preferences

I want providers with completed background checks. I want license or certification verification when applicable. I want references available before booking. I want Hope to help me understand what reference questions to ask. I understand Hope Care Connect is not for emergencies. I understand my family is responsible for deciding whether a provider is the right fit before services begin.

Payment to Join

Family membership required

To submit a care request and connect with available providers, you join Hope Care Connect for $10 per month or $60 per year. Monthly membership may be canceled anytime.

The first month is non-refundable once directory access is issued. If you cancel, your access ends at the end of the paid billing period. Yearly membership is non-refundable once directory access is issued.

Monthly Payment - $10 Yearly Payment - $60

Membership choice I understand family membership payment is required before Hope Care Connect processes my care request. I understand membership is non-refundable once directory access is issued, and cancellation ends access at the end of the paid billing period. I have submitted family membership payment or will complete payment before using my access number to view the provider directory. Your directory access number

Optional Family Insurance Interest

Interested in protecting you and your family? Complete a separate short form to request information and a personalized Insurance Quote consultation. The maximum number of children is 10. This is an optional service and not required to use with Hope Care Connect.

Insurance Quote Interest Form

Your email app will open so you can send this information to Hope Care Connect.