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Applicant Information
Name(Required)
First Last
Date of Birth(Required)
Address(Required)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone Number(Required)
Email Address
Enrolled in MassHealth?(Required)
- Yes
- No
- Unsure
Need assistance with any of the following? You may select more than one.(Required)
- Select All
- Bathing
- Dressing
- Toileting
- Mobility
- Being Fed
Currently lives with a Caregiver?(Required)
- Yes
- No
If you are completing this form for someone else, please complete the following:
Your Name
First Last
Your Phone Number
Your Email Address
Your Relationship to the Applicant:
Next Steps
Who should be contacted to arrange an intake appointment?(Required)
First Last
Phone(Required)
How did you hear about us?(Required)
- Referral/Word of Mouth
- Social Media
- Google Ad
- Newspaper Ad
- Other
Phone
This field is for validation purposes and should be left unchanged.

Name(Required)
First Last
Address(Required)
Street Address Address Line 2 City State ZIP Code

Note: You must reside in Massachusetts.
Phone Number(Required)
Email Address
Do you have a spare bedroom?
- Yes
- No
Briefly explain your caregiving experience:(Required)
How did you hear about us?(Required)
- Referral/Word of Mouth
- Social Media
- Google Ad
- Newspaper Ad
- Other

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Address

Adult Foster Care of the North Shore
63 Middle Street
Gloucester, MA 01930
978-281-2612 | Toll Free: 866-751-2616
Fax: 978-281-2223
[email protected]
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Who We Are
How We Help
Caregivers
Professionals
Did You Know

Hours

Office Hours Monday – Friday 9:00 am- 5:00 pm
After hours please call 978-281-2612 for assistance.