Request Case Aide Services

First Name*

Last Name*

Provider Number*

Please enter your provider number. If you have not yet been been approved by Secret Harbor, please complete the Intake Form, prior to requesting service. Your service cannot be approved unless you have have completed the verification process.

Date

Please enter the date you require service. PLEASE NOTE: service must be requested one week in advance, schedule up to one month in advance. Typical service window is between 3-4 hours.

Service starts?*

Please enter the time of day in which you request service to begin.

:

Service ends?*

Please enter the time of day in which the service will end.

:

Details*

Please tell us how you plan to utilize the Case Aid's support. Make sure to let us know any pertinent details, such as how many youth will be in the Case Aide's care, specific instructions, and any other information you wish to share. e.g. "Need to take younger sibling to the dentist, requesting case aide to supervise two remaining siblings (age 8 and 10) in the home while we are out."

Address*

Please list your home address. If you require service to happen outside your home, please note that in the Details section of this form.

Street Address Address Line 2 City State ZIP Code