Date
*
-
Month
-
Day
Year
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How did you hear about us?
*
Please Select
Better Business Bureau
News Station (FOX,CNN,ABC,CBS)
Search Engine
Internet Ad
A Place For Mom
Geriatric Care Manager/Social Worker
US Chamber of Commerce
Friend or Neighbor
Other
Your Full Name
*
First Name
Last Name
E-mail
*
Example: myname@example.com
Phone Number
*
Relationship to Care Recipient
*
Please Select
Son / Daughter
Son in-law /Daughter in-law
Relative
Self
Spouse
Parent
Friend
Other
Caregiver Needed For :
*
Single person
Couple with only one needing hands-on assistance
Couple whom both need hands-on assistance
Other
Care Recipients Name
First Name
Last Name
Care Recipient's Age
Known Conditions
None
General weakness
Stroke
Dementia/Alzheimers
Parkinsons
Diabetes
Recovering from acute injury (ex: broken bone)
Bedridden
On hospice
Second Care Recipient
First Name
Last Name
Second Care Recipient's Age
Known Conditions
None
General weakness
Stroke
Dementia/Alzheimers
Parkinsons
Diabetes
Recovering from acute injury (ex: broken bone)
Bedridden
On hospice
Needs physical assistance between 11pm and 7am
*
Please Select
Rarely to never
Once or twice a week
More then 2x per week
Not Sure
Does care recipient need assistance with transfers?
*
Please Select
No
Yes- but only partial assistance
Yes- full assistance (need to be carried or lifted)
Not sure
Other conditions or Special needs (if any)
Who is currently the care recipients caregiver?
No-one
Spouse
Family or friends
Privately hired aide / agency
Other
To the best of your knowledge, approx how long do you foresee needing the caregiver to work for your family? Best Estimate
1-6 months
6 -12 m
> 1 year
Tentative caregiver start date
-
Month
-
Day
Year
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Preferred Caregiver Gender
Female
Male
Doesn't matter
Minimum Caregiver Experience Required:
*
1 to 2 years
3+ years (+$$)
5+ years (+$$$)
Special Training / or Experience Requested
Example: Alzheimer Care, CPR etc..
We would like to have service: (Minimum of 5 days per week)
7 Days (requires 2 caregivers each month)
6 Day s a week
5 Days a week
Not sure
Live-in's living area (Check any that apply)
Private Bedroom
Dresser
Closet
Private Bathroom
Private TV
Computer
Cable
Internet access
Additional Amenities
Ex: private use of family car, Tues afternoons off, etc..
Which personality traits are you looking for in a caregiver?
Quiet
Mature
Youthful
Reserved
Talkative
Playful
Driver's License / Car required? (note: very few live-ins have their own cars)
*
Neither required
Driver's license required
Driver's license + car required (+$25 per day)
Additional tasks that you would like the caregiver to complete:
Prepare meals
Complete general housechores
Do laundry
Pet care
Driving care recipient
Walks /exercise with care recipient
Care recipients location
*
Street Address
Street Address Line 2
City
State
Zip Code
Residence type:
Please Select
Private home
Condo/Co-op/Apartment
Independent Living Residence
Assisted Living Facility
Other
Number of household members:
What pets are in the home?
Cats
Dogs
None
Other
Does anyone in the house smoke inside the home?
Yes
No
Closing Comments / Additional Things to Consider (Optional)
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