Inquiry Form

Gentle Shepherd Care Inquiry Form

Charlotte’s Only Nurse-Run, Holistic Eldercare Practice

We don’t compete with traditional home care agencies. We address root causes, not just
symptoms. Our clients choose us because they refuse to settle for conventional care.

Who needs care?

My parent My spouse Myself Other family member

Their current age

70-79 80-89 90+

What prompted you to seek eldercare support RIGHT NOW?

Current living situation

Living independently at home Living with family Assisted living/senior community Hospital/rehab (planning discharge)

Primary care needs (select all that apply)

Help with activities of daily living (bathing, dressing, etc.) Medication management Chronic condition management (diabetes, heart disease, etc.) Neurological conditions (dementia, Parkinson's, stroke recovery) Post-surgical/rehabilitation support Companionship and quality of life focus End-of-life/hospice support

What's most important to you in eldercare?

Nurse-led care that addresses root causes Dignity, comfort, and quality of life Slowing disease progression, not just managing symptoms Holistic approach (body, mind, spirit) All of the above

Have you worked with other home care agencies?

No, this is our first time seeking care Yes, and we're looking for something better Yes, and we're comparing options Currently using an agency but unsatisfied

If yes, what was missing from your previous experience?

What's your timeframe for starting care?

Immediate (within 1 week) Within 2-4 weeks 1-2 months Just gathering information

How did you hear about Gentle Shepherd Care?

Is there anything else we should know about your situation?

Name

Phone Number

Best time to reach you

Address

Auto-response: “Thank you for your inquiry. Our team will review your needs and contact you within 48 hours.”
Team reviews and qualifies
Qualified leads get consultation scheduled