teleCalm Service Application
Primary Caregiver (Account Holder) Information
teleCalm accounts are in the caregiver's name, not the name of the loved one.
Unlike traditional phone service, teleCalm considers the caregiver to be the account holder and their loved one to be the end-user. This allows the caregiver to be the primary point of contact for any questions and support interactions regarding the account.
Caregiver First Name
Caregiver Last Name
Caregiver Email Address
This will also be your user-id for the teleCalm Caregiver app
Caregiver Cell Number
Primary caregiver may receive service-related alerts
How did you hear about us?
Family or Friend
Senior Living
Internet Search (Google, Yahoo, Bing, etc.)
Support Group (In Person / Online)
Instagram
Facebook Ad
Google or YouTube Ad
Website
Other
Any additional details you can provide would be great!
Do you know how they found us?
What is the name of the senior living community?
Any idea what you searched for? Did you use Google, Bing, DuckDuckGo, etc.?
Was this in-person or online? Can you provide the name of the group?
Do you recall what website?
Shipping Address
Where should we ship the teleCalm adapter? This is usually the primary caregiver's address or another family member that lives near the loved one. On rare occasions, this may be a senior living community, but it is not recommended.
Ship To Name
(if different from Caregiver)
Street Address
Street Address 2
City
State
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip code
End User Information
Where will the adapter be located? This would be the physical address, including apartment or room number of the loved one.
This will also be used as the 911 address that emergency dispatchers will see if 911 is dialed.
Loved One's Name
What is your loved one's full name (first last)
Loved One's Age
Optional, but helpful
Residence Type
Where does your loved one reside?
Private Home / Apartment
Independent Living Community
Assisted Living Community
Memory Care Community
Skilled Nursing / Rehab Center
Community Name
Service Address
Apt / Room #
Service City
ST
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP
Does your loved one have dedicated internet?
If in a senior living, this does NOT include community wifi
No
Yes
I'm not sure
Why are we asking about internet?
teleCalm provides phone service that's easy to set up using our adapter. You can use it with the senior’s dedicated internet, but if they don't have internet, don't worry – it works just fine without it.
If they have internet, we'll send a cable to connect the teleCalm device to the internet box.
If you don’t have internet, the device will use its own built-in cellular service to keep them connected, as long as there is good cellular coverage in the resident's home/apartment.
Here's a quick video showing the easy setup
.
Are you needing to transfer (port) the existing phone number?
No
Yes
I'm not sure
Needing to keep the old phone number?
teleCalm provides a brand new phone number for your convenience. Many subscribers find that starting fresh is easier, especially when only adding a small number of trusted contacts.
However, if you need to port an existing phone number, we can help process that port request on your behalf, but it is NOT immediate. This process can take 2-3 weeks and there will be a $25 charge once porting is successful. More info on porting can be found
here
.
Any special instructions?
teleCalm's Terms of Service, including SMS messaging terms
All teleCalm subscribers must read and agree to teleCalm's
Terms of Service
, including SMS messaging terms, and grant teleCalm express permission to send automated and customer service-related text messages to my mobile phone [field17].
By checking this box you agree to receive recurring messages from teleCalm, Inc, Reply STOP to Opt out. Reply HELP for help. Message frequency varies. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages.
Agree?
NO, I do not agree
YES, I have read and agree with teleCalm's Terms of Service
Sorry, all subscribers must agree to our terms of service
Please contact teleCalm with any questions or concerns at
888-701-0411
Please contact teleCalm with any questions or concerns at 888-701-0411
Subscription Plan
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Lead Source Detail
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HubSpot Service Address
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Caregiver Full Name
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Signup Date
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Client Ref ID
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Stripe Payment URL
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Proceed to Payment
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