Home Care Plans Previous Next Please enable JavaScript in your browser to complete this form.Name *FirstLastGender *MaleFemaleDate of Birth *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *Effective Date *Hours - Monthly Premiums *Platinum - 10,000 Lifetime Membership Hours - $ 475.00Gold - 6,000 Lifetime Membership Hours - $ 295.00Silver - 3,000 Lifetime Membership Hours - $ 175.00Bronze - 1,500 Lifetime Membership Hours - $ 95.00Base (Only Available for Groups) - 600 Lifetime Membership Hours - $ 39.00Enrolling with a Household Member *YesNo* 10% Discount when enrolling with a household memberAre you able to live independently at this time? *YesNoAre you currently able to preform daily activities such as bathing, dressing, and transferring without assistance from anyone (including family members)? *Yes NoAre you aware that the True Freedom Homecare Plans are NOT insurance?YesNoReferring Organization or IndividualSubmit