Client form

For Short-Term Care, Long-Term Care, and other services fill out the application below on this page. We will follow up with you shortly. Taking the time to fully understand our client’s needs is what makes our placement process so successful. Before you begin working with us we ask that you fill out the application below. It details all of the specific requests you may have for your family’s specific situation and will help us make a placement or help us help you make a decision that is an appropriate choice. We are dedicated to making sure that you are completely happy with the process and the end result.The form below is not only a needs assessment, it specifies what you can expect from us as a client and is a contract defining our terms of service. We look forward to being an extension of your family and helping to make your life easier. Please call or text our office any time if you need additional assistance or simply would rather discuss by telephone at 877-553-4231.


You will be prompted to fill out billing information after this form is completed on the submission page. To complete the process you must fill out our secure billing collection form.

Client Form

Short-Term Care, Long-Term Care, and Due Diligence Services Application

    $42-55 per hour depending on location and case (during the current time we are experiencing shortage on staff and rates will be quoted per case) Custom Rates apply for Private Educators
    $45-65 per hour Night Nanny or NCS
    5% processing fee if Crunch Care employee process shopping transaction for client and we bill for items with receipt, no fee if client provides cash payment to shopper for items, hourly billing will be processed by client credit either scenario
    $150 Deposit 1+ day of service
    $250 Deposit 3+ days of service
    $500 Deposit 5+ days of service
    Deposit applied to balance if refund required will process at time of billing.

    Overtime in CA begins after 8 hours a day and 40 a week. Overtime in FSLA States after 40 hours in a week. See contract for more details.

    $4000 any search under 20-24 hours, 30 day replacement $5000 any search above 25 hours, 90 day replacement
  • If care is not needed put n/a
    By signing this form, you are agreeing to receive recurring messages from related to your request for information. Message and Data rates may apply. Carriers are not liable for delayed or undelivered messages. You also confirm that you have the authority to consent to receive text messages at the number you provided. Text help for help & stop to unsubscribe. No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties. Message frequency varies per user. Message and data rates may apply. Text HELP for help. Text STOP to unsubscribe. Link to Privacy Policy and Text Messaging Terms and Conditions:
  • Schedule and Assessment

    Please be as descriptive as possible when filling out the hours of care you will need. Specify if you will need a.m., p.m., or 24 hour shifts.
  • MM slash DD slash YYYY
  • Please print and retain all of our agreements as listed at the top of this page.
  • Fees for full employment services will be based on the original booking confirmation. Should the hours be extended they will be audited in our weekly billing based off time card review and will automatically charged to your billing credit card.
  • **Please print and retain a copy of your completed Client Application for your records.**
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