How can we help you?

Organization / Role *
Long Term Care OmbudsmanAlliance StaffAuthorized Advocate / Partner OrganizationOther

Is the resident aware of this request? *
YesNoNot applicable

Please describe the resident’s need and any relevant circumstances. *
(Include context such as impact on dignity, comfort, rights, safety, or wellbeing.)

What type of assistance is being requested? * (Check all that apply)
ClothingFootwearToiletries / Personal Care ItemsComfort Items (blankets, sensory items, etc.)Communication or Assistive ItemsOther essential item(s)

Is this request time-sensitive? *
YesNoNot sure

If yes, please briefly explain

Submit Request