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Our Team
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Strategic Plan
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Programs
Foster Care
Residential Treatment
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In-Home Support
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Request Case Aide Services
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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.
Month
1
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10
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12
Day
1
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Year
2025
2024
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2019
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2015
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1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Service starts?
*
Please enter the time of day in which you request service to begin.
:
Hours
Minutes
AM
PM
AM/PM
Service ends?
*
Please enter the time of day in which the service will end.
:
Hours
Minutes
AM
PM
AM/PM
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Email