Care Request Intake Form

Florida’s Secure Placement Request — Powered by ITM Care Connect™

Complete this short, secure form to begin your free care matching process.

There are no fees or obligations for families, case managers, or hospital staff. Once submitted, our system matches your request to licensed and available facilities based on your care needs, budget, and location.

Who Is Completing This Form?

Your Full Name *

Phone *

Email *

Preferred Contact Method *

Phone

Text

Best Time to Contact You *

Individual Needing Care

Full Name of Individual *

Age of Individual *

Gender of Individual *

Male

Female

Primary Diagnosis or Care Need

Mobility Level *

Fully Independent

Needs Some Assistance

Wheelchair Bound

Bedridden

Financial Information

Monthly Budget for Care *

Does the individual have a Power of Attorney (POA) or Legal Guardian? *

Yes

Power of Attorney (POA) or Legal Guardian Contact Information

Full Name of Power of Attorney *

Email of Power of Attorney *

Phone of Power of Attorney *

Address of Power of Attorney *

Medical & Behavioral Overview

Primary Physician or Hospital

Is the individual currently admitted to a hospital or rehab center? *

Yes

In which hospital facility individual is admitted? *

Any behaviors that may affect placement? *

Current Medications

Confidentiality Notice

By submitting this form, you authorize ITM Care Connect™ to share your

information with licensed facilities for the purpose of placement matching only.

We never sell data or release personal health information without consent.

I agree to the Terms of Service and Privacy Policy.
I understand ITM Care Connect™ is a marketing and referral platform, not a healthcare

provider.

Date *

Signature *

Clear