Online Intake Form

Begin your support with confidence!

Complete our secure online intake form to help us understand your family, your care needs, and the type of support you are looking for. Once submitted, our team will review your information and guide you toward the right next step with care, clarity, and compassion.

Step One

Complete the form

Please complete the entirety of the intake form to the best of your ability for each individual you would like support for.

Step Two

Schedule your intake call

Click here to schedule your intake call once you have completed our intake form.

Safe and confidential intake process

Helps us understand your care goals

For children, families, seniors, and caregivers

Response within 24 hours

Start Intake Form (780) 801-8955

After the form is submitted and your intake call is scheduled, our team will review your information and contact you with the next step in your care journey.

Confidential Submission

Culturally Responsive Care

Alberta-Based Support Team

Online Intake Form

Begin your support with confidence.

Complete this secure intake form so our team can understand your needs, connect you with the right service, and begin your care journey with clarity.

Step One: Complete the form Please complete the entire intake form to the best of your ability for each individual you would like support for.

Step Two: Schedule your intake call Once the form is complete, call us to schedule your intake call and discuss the next step.

Call to Schedule Intake: (780) 801-8955

Transportation CFS Support FSCD Support Respite Care Family Support Senior Care Cultural Care

1ARC Family Care Intake Form

Please share the details below. Fields marked with an asterisk are important for the first review. Your information will help our team respond with the right care pathway.

Primary Contact

First Name *

Last Name *

Phone *

Email *

Preferred Contact Method

Relationship to Client

Person Needing Support

Client First Name *

Client Last Name *

Client Type / Age Group

Date of Birth

Current Age

Gender

Indigenous Identity

Street Address / Service Address

City

Province

Postal Code

Where should services mainly take place?

Service Requested

Main Service Requested *

Urgency

Preferred Start Date

Desired Schedule

Secondary Services Needed

Transportation Services Children & Family Services Support FSCD Program Support Respite Care Family Support Services Senior Care

Days Requested / Availability

Care Needs & Safety Notes

Transportation Needed?

Funding Source

Mobility / Personal Care Needs

Diagnosis / Medical Notes

Allergies / Dietary Restrictions

Risk / Safety Notes

Behavioural / Mood / Sleep Notes

Cultural, Language & Communication Preferences

1ARC Family Care provides culturally responsive support. Share anything that helps us respect your language, faith, traditions, family structure, dietary needs, or Indigenous cultural care preferences.

Communication / Language / Cultural Preferences

Funding, Caseworkers & Care Team

FSCD or PDD Client?

FSCD/PDD Case Worker

CFS/CSS Client?

CFS/CSS Case Worker

Physician / Clinic

Pharmacy

Emergency Contact, Documents & Consent

Emergency Contact Name

Emergency Contact Phone

Emergency Relationship

Documents Link

Additional Notes

I consent to being contacted by 1ARC Family Care and understand that the information submitted will be reviewed for intake and care coordination purposes. *

After submitting, please call (780) 801-8955 to schedule your intake call.