• Caring for a loved one (e.g., family member, friend, or neighbor) can be tough to navigate alone. Our team is ready to help you find a solution to realistic care and support for your loved one. Please complete the intake form below with information about you and the person you care for. This information will help us know how we can assist you. If you would like help completing this form, please call us at (408) 320-3200, option 1.

    Upon completion of this intake form, you will gain access to the Sourcewise MyPlan text messages with real-time chat feature, receive 1 to 3 text messages a week with helpful information and guidance from our team straight to your phone. Text messages will come from the number 43386. We suggest saving this number as a contact in your phone with the name “Sourcewise MyPlan.” You can review the Terms and Conditions here: https://sourcewise.gomohealth.care/terms/

    In addition to the text messages, you will also receive access to the Sourcewise MyPlan Library of caregiver resources, customized with resources to meet your unique needs, as well as access to text with us in real time. You will receive a welcome message from our Chat line at (833) 728-1403 – it’s a good idea to save this number in your phone as “Sourcewise Chat.”

  • Please take a few minutes to answer the following questions about you as the primary caregiver signing up today.

  • (Select all that apply)

  • Please provide some additional information about the person you care for.

  • (Select all that apply)

  • To better help you, please tell us a little bit more about how you are feeling as a caregiver:

  • Rate on a scale from 1-10, where 1 = no stress and 10 = very high stress.
  • *(Respite care provides temporary relief from caregiving responsibilities. It could be scheduled time off a few hours once a week for a limited time or needed in an emergency situation to help the caregiver and their loved one)

  • Over the last 2 weeks, how often have you been bothered by the following problems?

  • If so, please note them here