Care Needs Schedule Caregiver Caretaker Review & Submit Save Progress Care Needs What is your address? Address 1 Address 2 City State Zip Code * Which daily activities does your need assistance with? Select all that apply. * More information can be provided later. Bathing Companionship Dressing and Grooming Exercise Housekeeping Meal Prep Medication Reminder Toileting Transportation Which of the following mobility tasks does your need assistance with? Catheter Care Gait Belt Hoyer Lift Pivot Transfer Total Bed Rest Are there any particular care concerns or medical conditions? More information can be provided later. ALS Alzheimer's Disease Arthritis Blood Disorders Cancer Recovery Cardiovascular Disorders COPD Dementia Depression Diabetes Gastrointestinal Disorders Hearing Disorders HIV/AIDS Home Health Care Hospice Care Multiple Sclerosis Neurological Disorders Orthopedic Care Palliative Care Parkinson's Disease Post Surgery Recovery Renal and Urological Disorders Respiratory Disorders Skin Disorders Stroke Trachetomy/Ventilation Vision and Eye Disorders Where would the financial resources that will be used for the caregiving services be coming from? * Savings Private Insurance Long Term Insurance Medicare Medicaid Who will be billed for the caregiving services? * (Adult) Children Parents Mother Father Others Next Save Progress Schedule Preferences What is the desired start date for care? * What is the expected duration of care? * Less than 1 month 1-3 months 4-6 months More than 6 months Not sure Please specify which days of the week care is needed. * M T W T F S S Monday Start Time: 01 02 03 04 05 06 07 08 09 10 11 12 00 15 30 AM PM End Time: 01 02 03 04 05 06 07 08 09 10 11 12 00 15 30 AM PM Tuesday Start Time: 01 02 03 04 05 06 07 08 09 10 11 12 00 15 30 AM PM End Time: 01 02 03 04 05 06 07 08 09 10 11 12 00 15 30 AM PM Wednesday Start Time: 01 02 03 04 05 06 07 08 09 10 11 12 00 15 30 AM PM End Time: 01 02 03 04 05 06 07 08 09 10 11 12 00 15 30 AM PM Thursday Start Time: 01 02 03 04 05 06 07 08 09 10 11 12 00 15 30 AM PM End Time: 01 02 03 04 05 06 07 08 09 10 11 12 00 15 30 AM PM Friday Start Time: 01 02 03 04 05 06 07 08 09 10 11 12 00 15 30 AM PM End Time: 01 02 03 04 05 06 07 08 09 10 11 12 00 15 30 AM PM Saturday Start Time: 01 02 03 04 05 06 07 08 09 10 11 12 00 15 30 AM PM End Time: 01 02 03 04 05 06 07 08 09 10 11 12 00 15 30 AM PM Sunday Start Time: 01 02 03 04 05 06 07 08 09 10 11 12 00 15 30 AM PM End Time: 01 02 03 04 05 06 07 08 09 10 11 12 00 15 30 AM PM Back Next Save Progress Caregiver Preferences Is there a gender preference for the caregiver? No Male Female Is live-in care needed? * In his/her own home (Live-out) In my 's home (Live-in) Is there a language preference for the caregiver? ASL Arabic Armenian Cantonese Chinese Mandarin English French German Greek Gujarati Hebrew Hindi Hmong Italian Japanese Korean Persian Polish Portuguese Russian Spanish Tagalog Urdu Vietnamese Please select the caregiver’s preferred certification level. Select all that apply. CPR CNA First Aid HHA LPN PCA RN Other (Specify) Pick two organizational skills that are the most important in a caregiver: * Detail Oriented Organized Punctual Tidy and Clean Pick three social skills that are the most important in a caregiver: * Articulate Empathetic Fun and Outgoing Good at Following Directions Good Listener Patient Talkative Team Player Pick two learning skills that are the most important in a caregiver: * Educated Quick Learner Smart Personal Characteristics Extraverted and enthusiastic Strongly Disagree Moderately Disagree Neither Agree Nor Disagree Moderately Agree Strongly Agree Critical and quarrelsome Strongly Disagree Moderately Disagree Neither Agree Nor Disagree Moderately Agree Strongly Agree Dependable and self-disciplined Strongly Disagree Moderately Disagree Neither Agree Nor Disagree Moderately Agree Strongly Agree Anxious and easily upset Strongly Disagree Moderately Disagree Neither Agree Nor Disagree Moderately Agree Strongly Agree Open to new experiences Strongly Disagree Moderately Disagree Neither Agree Nor Disagree Moderately Agree Strongly Agree Calm and reserved Strongly Disagree Moderately Disagree Neither Agree Nor Disagree Moderately Agree Strongly Agree Sympathetic and warm Strongly Disagree Moderately Disagree Neither Agree Nor Disagree Moderately Agree Strongly Agree Disorganized and careless Strongly Disagree Moderately Disagree Neither Agree Nor Disagree Moderately Agree Strongly Agree Calm and emotionally resilient Strongly Disagree Moderately Disagree Neither Agree Nor Disagree Moderately Agree Strongly Agree Conventional and by the book Strongly Disagree Moderately Disagree Neither Agree Nor Disagree Moderately Agree Strongly Agree Does your observe any of the below religious practices? Select all that apply. Attend religious services Dietary requirements Kosher foods Listen to services on the TV or radio No meat on Fridays Pray or meditate Vegetarianism Watch services on TV Read or study religious texts (Bible, Torah, Koran, etc.) Visits from religious leaders (clergy, rabbi, etc.) Back Next Save Progress Current State of Care Your asks for more help than he/she needs. Strongly Disagree Moderately Disagree Neither Agree Nor Disagree Moderately Agree Strongly Agree You feel stressed or strained when your are around. Strongly Disagree Moderately Disagree Neither Agree Nor Disagree Moderately Agree Strongly Agree You could do a better job in caring for your . Strongly Disagree Moderately Disagree Neither Agree Nor Disagree Moderately Agree Strongly Agree Overall, how burdened do you feel in caring for your ? Not burdened at all Somewhat burdened Very burdened Back Next Save Progress Complete the form below and click “Done” to submit your request. We will contact you within 24 hours with your caregiver candidates. Subject Line Your information First Name * Last Name * Email * Phone Number * Location: Your caregiver rate: Back Done Done Thank you for completing the care questionnaire! Please check your email for a message confirming your request. A care coordinator will be in touch soon to assist you. Until then, here are a few articles to help you with the homecare process: Helping Your Parent Prep for Aging in Place Adult Children Caring for Aging Parents Elder Care Service Options XClose Complete finding a caregiver through our other ways. Save my progress via email link Continue finding a caregiver via phone By entering your email, you can save your progress. Entering your email lets you save your care finder search. An email will be sent to your address with a link to resume your progress in finding a caregiver. Thank you, this tab will close in 7 seconds. Please enter your phone number and email. One of our care managers will be with you shortly. Thank you, finding the right caregiver isn’t easy! Thank you, we will follow up to your caregiver request with a call in the next 48 hours. Please check your email for a confirmation of your query.